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THEORY  AND 


THYROID  THERAPY 


LIBRARY 

OF  THE 

UNIVERSITY  OF  CALIFORNIA. 

•*  * 

Class 


THEORY   AND   PRACTICE   OF 
THYROID    THERAPY. 


Theory  and    Practice 


OF 


Thyroid  Therapy 

Being  some  experiences  of  the  results  of  Thyroid 
medication,  with  deductions  concerning  the  influence 
of  Thyroid  secretion  in  health  and  disease,  and  certain 
effects  of  drugs  and  various  circumstances  upon  Thyroid 
secretion 


A     BOOK     FOR     GENERAL     PRACTITIONERS 


BY 

HERBERT   EWAN    WALLER, 

M.R.C.S.  England,  L.R.C.P.  London. 

Honorary  Ancesthetist  Birmingham  Dental  Hospital 
Medical  Officer  Balsall  Heath  Provident  Dispensary 


NEW    YORK 

WILLIAM    WOOD    AND    COMPANY 
MDCCCCXI 


A 


3101-0^ 


PRINTED   IN   GREAT   BRITAIN. 


PREFACE. 


IN  offering  the  following  work  to  the  con- 
sideration of  the  Medical  Faculty,  I  wish  to 
acknowledge  my  indebtedness  to  the  numerous 
writers  to  whose  works  reference  is  made,  and 
in  particular  to  Dr.  Leonard  Williams,  whose 
writings  have  been  largely  responsible  for 
renewing  my  interest  in  this  particular  branch, 
which  has  always  appealed  to  me  as  being 
worthy  of  special  study.  My  aim  throughout 
has  been  to  collect  facts,  and  also  ideas  and 
theories  based  on  facts,  by  the  careful  con- 
sideration of  which  I  have  attempted  to  draw 
conclusions  and  so  advance  our  knowledge 
on  the  subject.  I  have  had  opportunities  of 
treating  a  considerable  number  of  patients 
from  the  thyroid  standpoint,  with  certainly 
more  success  than  I  should  have  anticipated. 
I  am  firmly  convinced  that  some  understand- 
ing of  thyroid  matters  is  essential  to  the 
practitioner  in  treating  every  case,  and  will 
materially  improve  his  success  in  the  treat- 
ment of  fully  one-fourth  of  his  patients.  I 
cannot  venture  to  hope  that  my  interpretation 

228585 


VI.  PREFACE 

of  the  facts  and  theories  under  consideration 
is  in  all  cases  correct.  The  science  of  thyroid 
therapy  is  like  all  other  sciences,  in  which  what 
we  deem  to  be  fact  to-day  may  eventually 
have  to  be  regarded  in  a  different  light.  But 
it  is  given  to  some  to  climb  to  success  by 
observing  the  mistakes  of  others.  So  if,  here 
and  there,  I  have  fallen  into  some  pit 
unawares,  others  may  thereby  be  enabled 
to  perceive  the  snare  and  keep  out  of  it. 
On  the  other  hand,  I  venture  to  think  the 
account  of  my  wanderings  into  this  little - 
known  land  may  prove  interesting  to  all, 
and  perhaps  of  assistance  to  some  in  enabling 
them  to  penetrate  still  farther.  At  present  the 
literature  on  the  subject  of  thyroid  therapy 
consists  for  the  most  part  of  monographs  of 
thyroid  treatment  in  many  and  various  diseases. 
Such  solitary  articles  are  read,  some  by  one 
practitioner,  some  by  another,  and  are  passed 
over  or  retained  according  to  the  circum- 
stances of  the  moment.  As  to  the  more 
advanced  works  on  such  complaints  as  Graves's 
disease  or  myxcedema,  the  general  practitioner 
is  apt  to  consider  them  for  the  most  part  out- 
side his  line.  He  has  occasionally  a  case  of 
either  complaint,  and  enough  general  examina- 
tion knowledge  to  give  him  rough  ideas  as 
to  treatment.  Whether  he  then  follows  up 
the  subject,  or  not,  depends  as  a  rule  on  the 


PREFACE  Vll. 

influence  of  the  patient,  and  the  general 
pressure  of  other  work  and  interests  at  the 
moment.  But  I  venture  to  say  that  few  prac- 
titioners, and  not  all  consultants,  have  any 
idea  of  the  individual  importance  to  them  of 
even  such  an  incomplete  knowledge  of  thyroid 
therapy  as  I  have  here  attempted  to  outline. 
I  must  also  take  this  opportunity  of  express- 
ing my  gratitude  to  Mr.  Rollinson-Whitaker, 
who  has  been  kind  enough  to  pass  on  to  me 
for  medical  treatment  some  of  his  cases  who 
were  not  at  the  moment  within  the  realms  of 
surgery,  and  has  thus  provided  me  with  most 
valuable  additional  material  for  observation. 

H.  EWAN  WALLER. 

41  Holly  Mount," 

65,  Church  Road,  Moseley, 
Birmingham. 


CONTENTS. 


CHAPTER  I. 

PAGE 

SOME  SYMPTOMS  AND  RESULTS  OF  THYROID 
INADEQUACY i 

Empirical  thyroid  therapy — Need  of  practical  basis — 
Minor  degrees  of  thyroid  insufficiency — Illustrative 
case — Thyroid  essential  for  calcium  assimilation — 
hence  insufficiency  causes  rickety  symptoms — Loss 
of  maternal  thyroid  a  cause  of  rickets — Enlarged 
tonsils  and  adenoids  associated  with  rickety 
symptoms — pigeon-breast — flat  chest — high  pala- 
tine arch — Origin  of  high  palate. 


CHAPTER    II. 

CAUSES  OF  INCREASE  OF  DENTAL  CARIES  AND 
THYROID  INSUFFICIENCY 14 

Dental  caries  a  result  of  thyroid  deficiency — Pro- 
duced by  measles— School  influence  on  increase  of 
measles,  &c. — hence  of  thyroid  deficiency — Loss 
of  lime-salts  in  modern  flour — Calcium  the  normal 
stimulant  of  thyroid  activity — Calcium  may  cure  or 
cause  constipation — Thyroid  medication  for  consti- 
pation— Loss  of  calcium  by  boiling  water — Influ- 
ence of  hard  and  soft  water  on  dental  caries — 
probably  acting  through  thyroid — Evasion  of 
maternity  and  lactation  a  cause  of  thyroid  de- 
generacy— Illustrative  case  of  converse  benefits — 
Summary  of  causes  of  increased  dental  caries  and 
thyroid  inefficiency —  Dental  caries  as  dental 
rickets. 


X.  CONTENTS 

CHAPTER  III. 

PAGE 

THYROID  A  VALUABLE  INGREDIENT  OF  MOTHER'S 

MILK 30 

Rickets  as  a  consequence  of  maternal  thyroid 
exhaustion — Freedom  of  savages  and  animals  from 
dental  caries  owing  to  influence  of  lactation — 
Survival  of  fittest — Favourable  influence  of  breast 
feeding  on  dentition— Case  illustrating  influence  of 
maternal  thyroid  on  urticaria — Rickets  and  thyroid 
depression  in  younger  members  of  long  families — 
Deprivation  of  breast  feeding  a  cause  of  adenoids — 
and  general  thyroid  deficiency  —  Recurrence  of 
enlarged  tonsils  and  adenoids  after  removal — 
Results  of  thyroid  medication— Rickets  almost  un- 
known among  infants  at  breast — Animals  deprived 
of  breast  milk  die  of  acute  rickets — Successful 
substitutes  for  breast  milk  in  case  of  lion  cubs — 
inferences  —  Importance  of  cream  in  infant 
feeding — probably  a  thyroid  carrier — Cod  liver  oil — 
Rickets  primarily  of  maternal  origin  —  Milk 
damaged  by  boiling. 

CHAPTER  IV. 

FAT  AND  THYROID  ACTIVITY       45 

Effect  of  fat  on  thyroid  activity— Thyroid  treatment 
of  obesity — Adiposis  dolorosa — Natural  likes  and 
dislikes  founded  on  physiological  or  pathological 
principles — illustrations — Vomiting  of  pregnancy — 
Thyroid  activity  and  pancreatic  inhibition — 
consequent  inability  to  digest  fats  in  Graves's 
disease — Harmful  influence  of  fats  in  Graves's 
disease— and  favourable  results  of  fat  deprivation. 

CHAPTER  V. 

GOITRE— CALCIUM  AND  THE  THYROID  GLAND 58 

Origin  of  goitre — Germ  theory — Calcium  theory — 
Adenoma — Calcium  as  a  stimulant  to  thyroid 
activity — may  produce  exhaustion  —  Temporary 
myxcedema  induced  by  calcium  —  Calcium  in 
Graves's  disease  —  objections  —  Indications  for 
calcium  and  thyroid — Urticaria  sometimes  a  result 
of  thyroid  excess — Urticaria  major — Causes  of 
urticaria. 


CONTENTS  XI. 

CHAPTER   VI. 

PAGE 

GOITRE— IODINE  AND  THE  THYROID  GLAND    72 

Activity  of  enlarged  thyroid — Nature's  cure — Un- 
favourable factors  in  treatment  —  Fallacious 
measurements  —  Menopause  —  Activity  of  goitre 
from  surgical  standpoint — Effect  of  atropine — 
Diminished  percentage  of  iodine  in  enlarged 
thyroids  —  Iodine  deficit  possibly  apparent  not 
actual — Possible  causes  of  deficit — Dissipation  of 
iodine  by  calcium — Iodine  deficiency  as  a  cause 
of  goitre — Disappointing  results  of  iodine  as  a 
remedy — other  factors  —  Comment  on  thyroid- 
ectomy. 

CHAPTER  VII. 

IODINE  AND  GRAVES'S  DISEASE 85 

Goitre  in  Graves's  disease — lodoform  poisoning  and 
Graves's  disease  —  Graves's  disease  not  due  to 
excessive  intake  of  iodine — or  diminished  output — 
Iodine-free  diet — Influence  of  meat  on  thyroid 
activity — Graves's  disease  due  to  explosion  in  iodine 
stores — Cause  of  explosion — Surgical  treatment- 
Symptomatic  treatment — Various  remedies — Case 
for  thyroid  administration  in  Graves's  disease. 

CHAPTER  VIII. 

LYMPHATIC  GLANDS  AND  GRAVES'S  DISEASE 98 

Graves's  disease  possibly  resembles  diabetes  in  varied 
modes  of  origin — Enlargement  of  lymphatic  glands 
in  Graves's  disease  and  thyroid  insufficiency — 
Lymphadenoma  —  Thymus  —  Lymphatic  gland 
feeding  as  a  remedy  for  Graves's  disease. 

CHAPTER    IX. 

THYROID  AND  ECZEMA       106 

Case  of  chronic  eczema  with  hyperthyroidism — 
Treatment  and  results — Thyroid  and  toxins — 
Rheumatoid  arthritis — Thyroid  and  acne— Par- 
oxysmal thyroid  activity  and  exhaustion — 
Symptoms  common  to  Graves's  disease  and  thyroid 
deficiency — Possible  deterioration  of  secretion  in 
Graves's  disease. 


Xll.  CONTENTS 

CHAPTER  X. 

PAGE 

THYROID  AND  ARSENIC      116 

Arsenic  as  an  ingredient  of  thyroid  gland — Effect  on 
thyroid  activity — Thyroid  activity  and  fatigue — 
Arsenic  and  acne  —  lymphadenoma  —  psoriasis — 
eczema — Arsenic  as  a  guardian  for  the  thyroid 
gland — Objections  to  arsenic  and  iodides  in 
goitre — Different  effect  of  large  and  small  doses  in 
goitre — lodism  —  Arsenic  in  consumption  and 
cancer — Effect  of  arsenic  and  phosphorus  on  bone 
formation — Thyroid  in  asthma  —  Pathology  of 
asthma. 

CHAPTER  XI. 

THE  INFLUENCE  OF  SALICYLATES  AND  KINDRED 
DRUGS  ON  THYROID  ACTIVITY 131 

Relation  of  thyroid  activity  to  fever — Action  of 
salicylates — Thyroid  depression  produced  by  large 
doses — Constipation  produced  by  salicylates — 
Salicylates  in  Graves's  disease. 

CHAPTER  XII. 

GENERAL  CONSIDERATIONS          141 

Thyroid  treatment  of  degenerates — Case  of  im- 
becility —  paralytic  —  general  cases  —  Dosage — 
Thyroid  a  protection  against  toxins— Nocturnal 
enuresis — Thyroidorrhcea — Thyroid  administration 
versus  thyroid  stimulation— Hints  on  administra- 
tion and  dispensing  of  thyroid. 


THEORY  AND   PRACTICE   OF 
THYROID  THERAPY. 


CHAPTER    I. 

Some  Symptoms  and   Results  of  Thyroid 
Inadequacy. 

THERE  is  a  large  and  apparently  utterly 
diverse  group  of  diseases  and  ailments  for 
which  thyroid  gland  has  been  prescribed,  often, 
it  is  feared,  without  any  intelligent  understand- 
ing of  the  objects  to  be  attained,  or  how  the 
process  is  to  be  arrived  at.  When  one  sees 
such  a  list  as  myxcede'ma,  cretinism,  obesity, 
puerperal  eclampsia,  simple  goitre,  exophthal- 
mic goitre,  psoriasis,  lupus,  eczema,  cheloid, 
syphilis,  tetany,  haemophilia,  torticollis,  acrome- 
galy,  ununited  fracture,  malignant  disease,  beri- 
beri, certain  diseases  of  the  eye  and  ear, 
haemorrhage  from  the  uterus,  mental  diseases, 
backwardness  of  children,  nocturnal  enuresis, 
enlarged  tonsils  and  adenoids,  alopecia,  and 
many  more,  one  is  at  first  sight  driven  to  the 
conclusion  that  anyone  who  prescribes  thyroid 
for  such  diverse  conditions  is  thyroid  mad,  or 
else  acts  on  the  plan,  "  When  in  doubt,  give 
i 


2  THYROID    THERAPY 

thyroid."  And  the  list  I  have  given  is  not 
exaggerated.  I  have  quoted  chiefly  from  one 
accessible  to  most  general  practitioners,  includ- 
ing a  few  diseases  from  various  articles  I  have 
read  on  the  subject,  and  could  extend  the  list 
considerably. 

In  the  following  pages  I  shall  endeavour  to 
discuss  the  subject  from  a  rational  point  of 
view,  so  far  as  I  have  been  able  to  elucidate 
the  matter  from  my  own  observations  and 
experience  in  a  considerable  number  of  cases, 
and  also  from  a  consideration  of  the  views  of 
many  writers  on  various  aspects  of  the  influence 
of  the  thyroid  on  the  body,  and  how  thyroid 
activity  may  be  affected  by  disease  and 
different  conditions  of  metabolism,  and  also 
by  various  drugs.  The  importance  of  this 
matter  in  practical  medicine  can  hardly  be 
over-rated,  seeing  that  thyroid  secretion  is 
probably  to  a  large  extent  responsible  for 
many  of  the  little  details  of  daily  life,  the  sum 
of  which  makes  all  the  difference  between 
being  robust  and  delicate,  enjoying  life  or 
being  a  martyr  to  various  petty  discomforts. 
Myxcedema  and  Graves's  disease  must  be  taken 
as  the  two  extremes  of  thyroid  secretion — 
myxcedema,  of  course,  representing  complete 
failure  of  secretion  and  Graves's  disease  the 
utmost  excess.  But,  it  is  not  too  much  to  say 
that  the  intermediate  conditions  of  thyroid 


SYMPTOMS    AND    RESULTS  3 

secretion  are  just  as  important  as  the  two  con- 
ditions just  mentioned. 

The  minor  degrees  of  thyroid  insufficiency 
have  been  admirably  described  by  Leonard 
Williams,  in  an  article  in  Folia  Therapeutica 
for  October  1909,  quoted  in  full  in  the 
Medical  Review,  May  1910.  This  article 
contains  food  for  much  thought,  but  to  put  the 
matter  very  briefly,  Leonard  Williams  shows 
that  one  of  the  most  important  functions  of  the 
thyroid  gland  is  that  of  fixing  the  calcium  salts 
of  the  body.  He  points  out  further  the  re- 
lationship of  thyroid  activity  to  menstruation 
and  pregnancy,  and  enumerates  various  minor 
signs  of  thyroid  insufficiency,  such  as  the 
presence  of  enlarged  tonsils  and  adenoids, 
which  are  an  attempt  on  the  part  of  the 
organism  to  supply  a  secretion  that  is  lacking. 
His  evidence  that  nocturnal  enuresis  is  due  to 
failure  of  thyroid  function  is  indisputable. 

Other  minor  symptoms  referred  to  are  sub- 
normal temperature,  hyper-sensitiveness  to  cold,^ 
loss  and  scantiness  of  hair,  premature  greyness, 
dysmenorrhcea  and  periodical  migraine,  and 
excessive  dental  caries.  And  he  also  points 
out  that  thyroid  depression  is  liable  to  follow 
anv,J*£UteJllness.  Now  many  of  these  sym- 
ptoms were  well  illustrated  in  a  case  under  my 
own  care,  in  whom  thyroid  extract  worked 
marvels.  The  case  is  an  extreme  type  of  a 


4       %  THYROID    THERAPY 

common  variety.  I  made  his  acquaintance  at 
the  Dental  Hospital.  His  initials  were  A.  T., 
and  his  age  was  6  years.  He  was  a  tiny 
little  fellow  only  3  ft.  high,  and  weighing 
28  Ib.  All  his  teeth  were  terribly  decayed. 
He  looked  pale  and  ill,  and  his  hair  was  very 
scanty.  It  was  not  difficult  to  elicit  from  his 
mother  that  the  child  was  never  well.  She 
had  in  fact  been  taking  him  to  hospitals  (she 
named  two  well-known  institutions)  for  several 
years  regularly,  and  he  had  been  taking  a  lot 
of  cod  liver  oil,  but  she  could  not  see  that  he 
was  any  better.  All  she  had  been  told  as  to 
the  nature  of  his  malady  was  that  it  was 
rickets.  Etiologically  this  was  true,  but  the 
child  was  not  in  any  way  deformed,  nor  had  he 
beaded  ribs.  His  skull  was  of  a  rickety  type, 
and  he  had  a  big  belly,  but  no  superfluous  flesh 
on  body  or  limbs.  He  was  always  fretful, 
cold  and  tired.  She  had  great  difficulty  in 
feeding  him,  as  he  never  wanted  food.  Water 
was  the  thing  he  craved  for,  and  that  to  such 
an  extent  that  he  actually  drank  the  water  in 
which  the  flowers  were  placed  at  school.  His 
mother  was  always  endeavouring  to  keep  the 
water  out  of  his  way,  as  otherwise  he  drank 
far  more  than  she  thought  good  for  him.  I  had 
the  quantity  of  urine  measured  on  several  occa- 
sions, but  it  was  not  excessive,  a  little  over 
a  quart  in  twenty-four  hours,  and  contained 


SYMPTOMS    AND    RESULTS  5 

neither  albumin  nor  sugar.  He  was  a  good 
deal  smaller  than  his  younger  brother,  aged  4, 
and  the  mother  'attributed  his  ill-health  to  the 
fact  that,  while  pregnant,  she  was  nursing  his 
father  through  a  serious  illness  for  five  months 
and  was  often  short  of  food.  Now  thyroid 
tablets  at  the  rate  of  ij  gr.  to  i\  gr.  a  day 
worked  wonders  for  this  little  boy.  He  be- 
came a  happy  child  instead  of  a  miserable 
one.  His  appetite  improved  to  such  an  ex- 
tent that  his  mother,  a  poor  woman  with  four 
children,  could  appreciate  the  difference  in  the 
bread  bills.  He  cried  for  his  rice  pudding. 
His  thirst  was  much  less,  though  at  the  time 
of  writing,  his  mother  tells  me,  he  always  asks 
for  a  glass  of  water  when  he  comes  down  in 
the  morning,  and  also  as  soon  as  he  gets  home 
from  school.  I  have  noticed  this  symptom! 
of  thirst  in  several  other  cases  of  thyroid! 
deficiency. 

He  would  now  play  contentedly  in  the 
garden  in  the  coldest  weather,  though  pre- 
viously he  was  always  cowering  down  by  the 
fire.  His  hair  commenced  to  grow,  and  had  to 
be  cut  as  often  as  that  of  other  children.  His 
colour  improved  immensely.  He  commenced 
to  increase  in  height  at  the  rate  of  J  in.  in 
six  weeks,  and  had  grown  if  in.  in  six 
months.  I  must  lay  stress  on  this  growth, 
because  he  was  7  in.  below  the  average 


6  THYROID    THERAPY 

height  for  his  age  at  the  beginning  of  the 
thyroid  treatment,  and  the  average  rate  of 
growth  for  a  boy  of  his  age  is  3  in.  a  year. 
He  also  increased  duly  in  weight.  His 
mother  was  naturally  delighted,  and  loud  in 
her  affirmations  of  what  her  neighbours  and 
the  boy's  school  teachers  said  as  to  the  evident 
difference  in  the  child.  Nor  could  there  be  any 
doubt  as  to  cause  and  effect,  because  the  drug 
was  left  off  for  a  fortnight  on  several  occasions 
during  the  earlier  stages  of  treatment,  and  the 
child  was  never  so  well  when  not  taking  it, 
improvement  immediately  following  when  he 
resumed  it.  He  has  also  been  able  to  take 
advantage  of  his  calcium  supply,  as  evidenced 
by  the  fact  that  his  first  permanent  molars  and 
his  central  incisors  have  now  erupted,  and 
appear  to  be  all  that  could  be  desired,  though, 
as  already  mentioned,  the  whole  of  his  tem- 
porary teeth  were  carious. 

Now  the  importance  of  this  function  of  the 
thyroid  gland  in  enabling  the  body  to  make 
use  of  calcium  salts  can  hardly  be  over-rated. 
The  hall-mark  of  rickets  of  the  fully-developed 
type  is,  I  suppose,  the  obvious  deficiency  of 
calcium  salts  in  the  bones,  and  the  resulting 
deformity,  though  this  is  still  further  enhanced 
by  weakness  of  ligaments  and  muscles. 

And  while  many  of  the  symptoms  already 
referred  to  as  marks  of  thyroid  deficiency  are  . 


SYMPTOMS    AND    RESULTS  J 

present  in  nearly  every  case  of  rickets,  it  is 
the  "  rickety "  condition  of  the  skeleton  that 
gives  the  name  to  the  disease,  whether  we 
accept  the  Anglo-Saxon  or  the  Greek  ety- 
mology of  the  word.  Probably  there  is  hardly 
a  medical  man  who  has  not  at  some  time  pre- 
scribed calcium  in  some  form  for  such  a  case, 
only  to  be  disappointed  in  the  results.  I  find, 
however,  that  Treves's  "  System  of  Surgery  " 
says,  "  The  administration  of  phosphate  of 
lime  is  of  little  use,  being  mainly  excreted  in 
the  urine,  a  proof  that  want  of  power  to 
assimilate  the  lime  salts  is  rather  the  cause  of 
defective  ossification  than  deficiency  of  lime 
salts  in  the  diet." 

I  think  that  anyone*who  will  investigate  the 
evidence  already  to  hand  and  pursue  the  sub- 
ject further  on  his  own  account,  cannot  fail  to 
be  convinced  that  the  connecting  link  is,  as 
Leonard  Williams  insists,  the  activity  of  the 
thyroid  gland. 

The  condition  of  rickety  children  of  course 
varies,  but  the  matter  is  not  difficult  to  explain 
on  this  assumption  as  to  the  etiology. 

One  child  may  still  show  all  the  symptoms 
of  thyroid  insufficiency  already  enumerated. 
In  another,  the  thyroid  gland  may  have 
recovered  itself,  and  only  left  results  of  the 
damage  already  done.  In  such  a  case  we  may 
suppose  that  some  debilitating  cause  has  been 


8  THYROID    THERAPY 

at  work,  and  by  upsetting  thyroid  secretion 
has  induced  a  calcium  famine  of  longer  or 
shorter  duration.  Accordingly,  the  softened 
bones  yield  and  various  results  occur — crooked 
limbs  or  spine,  or  contracted  pelvis,  or  pigeon 
breast — according  to  the  nature  of  the  strain 
that  is  put  on  the  inadequately  calcified  bones, 
and  also  according  to  the  longer  or  shorter 
duration  of  this  thyroid  inadequacy. 

Personally,  however,  I  am  of  opinion  that 
rickets  in  its  worst  form,  starting  as  it  then 
does  in  the  earliest  months  of  life,  is  primarily 
caused  by  depriving  the  infant  of  the  benefit  of 
maternal  thyroid  activity,  the  infant's  own 
thyroid  secretion  being  invariably  unequal  to 
its  requirements  at  birth.  This  most  interest- 
ing subject  will  be  fully  discussed  further  on. 

The  association  of  pigeon  breast  with  en- 
larged tonsils  (adenoids  were  nothing  accounted 
of  apparently)  was  first  noted  by  Dupuytren 
about  1826,  and  this  combination  of  maladies 
has  been  duly  set  forth  in  the  text-books  ever 
since.  But  in  those  days  probably  only 
extreme  cases  were  noted,  as  it  was  no  unusual 
thing  to  wait  two  or  three  years  "  till  the  child 
was  better  able  to  stand  the  operation." 
Nowadays,  I  venture  to  say  the  proportion  is 
exceedingly  small.  And  when  pigeon  breast 
occurs,  I  suggest  that  probably  some  other  fac- 
tor has  been  at  work,  such  as  hooping-cough 


SYMPTOMS    AND    RESULTS  9 

or  laryngismus  stridulus.  The  latter  disease  is 
a  special  perquisite  of  rickety  children,  and  it 
is  only  natural  that  the  uncalcified  bones 
should  yield  under  the  strain.  But  it  has 
already  been  mentioned  that  enlarged  tonsils 
and  adenoids  are  a  confession  of  thyroid  in- 
adequacy on  the  part  of  the  organism,  so  we 
need  not  marvel  if  they  are  put  into  the  patho- 
logical picture,  which  after  all  only  represents 
some  of  the  various  phases  of  the  rickety  type. 
The  moral  of  this  is,  that  when  you  remove 
the  tonsils  and  adenoids  you  must  be  prepared 
to  give  thyroid.  But  an  amazing  benefit 
seems  sometimes  to  accrue  to  a  child  as  the 
direct  result  of  the  operation.  I  have  won- 
dered whether  suddenly  depriving  the  system 
of  this  added  secretion  has  not  in  these  cases 
acted  as  a  powerful  stimulus  to  the  thyroid 
gland.  The  gland,  at  one  time,  unable  to 
secrete  sufficiently,  was  helped  by  Nature,  who 
provided  a  substitute,  a  harmful  one  no  doubt, 
but  still  a  substitute.  So  the  thyroid  took  a 
holiday  and  got  well,  but  finding  the  substitute 
there,  had  no  need  to  work.  When,  however, 
the  substitute  and  its  wickedness  were  re- 
moved, the  thyroid,  now  fully  capable  and 
under  sufficient  stimulus,  stepped  into  the 
breach,  and  all  was  well. 

But    nowadays    the    ever-watchful    surgeon 
has  usually  removed  the  tonsils  and  adenoids, 


IO  THYROID    THERAPY 

almost  as  soon  as  Nature  has  accomplished 
their  development,  and  the  thyroid,  not  having 
had  any  assistance  is  unready  for  work.  In 
such  cases  a  little  well-directed  thyroid  medica- 
tion is  obviously  indicated.  As  a  matter  of 
fact,  however,  those  with  enlarged  tonsils  and 
adenoids  are  presumably  less  liable  to  suffer 
from  calcium  famine  than  those  without.  The 
secretion  is  worth  something  in  spite  of  its 
pathological  origin.  This,  as  Leonard  Wil- 
liams has  shown,  is  proved  by  the  fact  that 
other  symptoms  of  thyroid  inadequacy,  such 
as  nocturnal  enuresis,  may  become  worse  after 
the  removal  of  the  tonsils  and  adenoids,  and 
also  by  the  fact  that  administration  of  thyroid 
causes  atrophy  of  these  pathological  sub- 
stitutes. But  if  pigeon  breast  is  not  now  so 
commonly  associated  with  tonsillar  hypertrophy 
and  nasal  obstruction  as  formerly,  it  must  be 
conceded  that  the  sufferers  are  prone  to  have 
narrow  and  flattened  chests.  This  may  be 
partly  the  result  of  obstructed  inspiration,  but 
is  probably  rather  due  to  the  action  of  the 
diaphragm  pulling  the  unduly  yielding  ribs 
inwards,  as  it  contracts  during  inspiration. 
But  there  is,  I  think,  yet  another  factor. 
Children  with  big  tonsils  and  adenoids  com- 
monly exhibit  another  feature  of  thyroid  in- 
sufficiency, namely,  hypersensitiveness  to  cold, 
so  they  unconsciously  adopt  the  attitude  of 


SYMPTOMS    AND    RESULTS  I  I 

greatest  self-protection — namely,  with  the 
shoulders  and  arms  thrown  forward  and  a 
slight  stoop.  One  never  sees  a  man,  shivering 
with  cold,  yet  with  head  erect  and  chest  ex- 
panded, except  perchance  a  soldier  on  parade. 
The  lateral  pressure  of  the  arms  on  the  chest 
and  the  generally  huddled  up  position  of  the 
shivering  child  is  bound  to  produce  its  effect 
if  long  continued  during  the  growing  period, 
especially  when  the  bones,  though  not  so  soft 
as  in  a  case  of  well-marked  "  rickets,"  are  prob- 
ably, to  some  extent,  deficient  in  lime  salts. 

There  is  another  common  deformity  so  fre- 
quently associated  with  enlarged  tonsils  and 
adenoids  that  for  a  long  time  it  was  thought  to 
be  a  natural  result.  I  refer  to  the  high  palate, 
in  which  condition  the  cavity  of  the  mouth 
encroaches  on  that  of  the  nose,  thus  lessening 
the  facility  of  nasal  respiration  and  imparting  a 
peculiar  tone  to  the  voice  by  interfering  with 
the  efficiency  of  the  hard  palate  as  a  sounding 
board.  Leonard  Williams,  however,  points 
out  what  has  also  been  noted  by  other  ob- 
servers, that  many  patients  who  have  the  high 
arch  are  free  from  enlargement  of  the  tonsils 
and  presence  of  adenoids,  and  he  tells  us 
that  StClair  Thomson  has  observed  that  the 
palates  of  children  whose  tonsils  and  adenoids 
he  removed  have  even  become  increasingly 
arched  after  the  operation.  We  are  driven  to 


12  THYROID    THERAPY 

the  conclusion,  therefore,  that  the  deformity  is 
due  to  yielding  of  the  bones  under  some  stress, 
just  as  other  deformities  are  produced  in 
rickets.  In  short,  the  primary  cause  is  thyroid 
insufficiency,  which  involves  calcium  deficiency. 
I  am  not  well  enough  up  in  the  mechanics  of 
the  jaw  to  say  what  stress  may  be  present 
which  could  cause  the  palate  to  yield  when 
insufficiently  calcified,  but  I  suggest  that  it 
might  be  the  pressure  of  the  tongue  in  the  act 
of  swallowing.  One  can  readily  imagine  that 
if  the  mouth  is  habitually  used  as  an  air- 
passage  instead  of  the  nose,  there  is  at  least  no 
encouragement  to  the  development  of  a  free 
nasal  passage.  Also,  if  the  mouth  is  practically 
never  shut  there  can  be  no  effective  upward 
pressure  of  the  teeth  of  the  upper  jaw  by  those 
of  the  lower,  which  pressure  would  tend  to 
flatten  out  and  spread  the  palate.  But  neither 
of  the  latter  factors  could  be  responsible  for  the 
origin  of  a  high  palate  in  the  absence  of  nasal 
obstruction,  which  is  not  always  present, 
though  they  might  well  require  attention 
when  attempting  to  correct  the  deformity. 
It  has  been  pointed  out  by  Leonard  Williams 
in  the  paper  already  referred  to,  that  many 
cases  of  rickets,  enlarged  tonsils  with  adenoids, 
and  nocturnal  enuresis  will  be  found  on 
inquiry  to  have  dated  from  one  of  the  in- 
fantile febrile  diseases,  which  has  induced  in 


SYMPTOMS    AND    RESULTS  13 

the  first  case  what  I  have  termed  a  calcium 
famine  ;  in  the  second  a  pathological  attempt 
at  compensation  ;  and  in  the  third  a  condi- 
tion not  so  easy  to  explain,  but  one  for  which, 
in  the  majority  of  my  own  cases,  thyroid  gland 
has  proved  itself  the  specific  that  Leonard 
Williams  claims  it  to  be. 


CHAPTER  II. 

Causes  of  Increase  of  Dental  Caries  and 
Thyroid  Insufficiency. 

I  NOW  wish  to  show  that  this  calcium  famine 
in  a  minor  degree  almost  invariably  occurs  as 
a  sequel  of  the  febrile  diseases  of  childhood, 
and  that  in  the  form  of  dental  caries.  Dental 
caries  is  a  subject  of  vast  importance,  and  one 
which  is  being  discussed  all  over  the  country 
at  present,  though  I  have  not  heard  any  men- 
tion of  thyroid  gland  in  the  discussions ;  but 
as  Leonard  Williams  points  out,  an  undue 
amount  of  dental  caries  should  always  excite 
a  suspicion  of  thyroid  inadequacy.  This  point 
was  well  shown  in  the  first  case  quoted. 

It  is  now  some  fourteen  years  since  a  London 
dentist — then  in  the  first  ranks  of  his  profes- 
sion, now,  I  regret  to  say,  dead — taught  me 
that  it  is  very  common  to  find  symmetrical 
decay  of  the  permanent  molars,  perhaps  especi- 
ally the  "sixes,"  as  the  result  of  measles 
or  some  other  child's  complaint  occurring 
shortly  before  or  soon  after  their  eruption. 
And  many  times  I  have  observed  the  truth 
of  this  fact,  and  also  gained  to  myself  credit 


THYROID    INSUFFICIENCY  15 

for  great  intuition  by  a  judicious  inquiry  based 
on  this  assumption.  I  see  no  reason  why  the 
same  should  not  hold  good  for  the  other  teeth. 
The  molars  are  of  course  larger  and  require 
more  nutriment,  and  are  therefore  more  likely 
to  be  affected  by  this  transient  calcium  famine 
— the  result  of  thyroid  depression. 

Now  let  us  turn  for  a  moment  to  Smale 
and  Colyer's  authoritative  work  on  diseases 
of  the  teeth.  "  In  endeavouring  to  ascertain 
the  cause  (of  the  increase  of  dental  caries)  it 
may  be  interesting1  and  instructive  to  remember 
that  the  teeth  have  not  alone  suffered,  marked 
deterioration  having  taken  place  in  other 
organs,  as  evidenced  by  the  increase  of  defec- 
tive eyesight  and  tendency  to  hypertrophy  of 
adenoid  tissue  in  the  naso-pharynx."  It  is 
indeed  ''interesting  and  instructive,"  inasmuch 
as  thyroid  inadequacy  is  responsible  both  for 
caries  and  adenoids.  We  see  here,  I  think, 
the  influence  of  universal  education  in  spread- 
ing the  minor  infectious  complaints,  and 
incidentally  also  in  producing,  or  perhaps 
sometimes  only  making  evident,  defective 
eyesight. 

Our  inquiry  into  the  cause  of  increased 
dental  caries  is  therefore  now  resolved  into 
another  question — namely,  What  is  the  cause 
of  the  decrease  of  thyroid  activity  ?  I  have 
just  given  one  answer  to  this  question  — 


I 6  THYROID    THERAPY 

namely,  the  spread  of  infectious  complaints 
in  childhood  inseparable  from  universal  school 
education.  The  schools  are  undoubtedly  the 
happy  hunting  ground  for  the  germs  of 
measles,  scarlet  fever,  diphtheria,  hooping- 
cough,  mumps,  and  such  like.  Doubtless, 
prizes  given  for  uninterrupted  attendance  con- 
tribute towards  this  spread  of  infection,  as 
many  scholars  are  thereby  induced  to  attend 
school  during  the  early  and  highly-infectious 
period  of  such  a  disease  as  measles,  The  rash 
is  not  observed  till  about  the  fifth  day,  and 
in  a  mild  case  an  enthusiastic  child  could  easily 
stand  out  against  the  initial  symptoms.  The 
same  applies  for  a  shorter  period  to  the  initial 
sore  throat  of  scarlet  fever  or  to  diphtheria. 
Also  to  the  early  stage  of  hooping-cough. 
And  not  only  the  attendance  prizes  are  at 
fault,  but  also  the  continual  harassing  of 
attendance  officers,  however  worthy  the  object. 
The  present  position  is  that  parents  are  afraid 
to  keep  a  child  from  school  if  it  is  possible  for 
him  or  her  to  get  there.  Unless  a  doctor's 
certificate  be  forthcoming,  there  is  likely  to 
be  trouble.  A  doctor's  certificate  may  mean 
expense,  and  unless  the  child  is  obviously  ill, 
the  mother  does  not  know  that  the  certificate 
will  be  forthcoming.  So,  instead  of  waiting 
to  see,  she  thinks  she  will  be  on  the  right  side 
by  sending  the  child  to  school.  The  school 


THYROID    INSUFFICIENCY  17 

is  closed  as  a  rule  when  about  half  the  scholars 
have  succumbed  to  the  epidemic  that  ensues. 
Measles  is  a  particularly  common  antecedent 
of  adenoids. 

Another  reason  for  the  increase  of  dental 
caries  may  perhaps  be  found  in  the  loss  of 
lime  salts  involved  in  the  modern  preparation 
of  flour.  This  suggestion  is  the  one  commonly 
favoured,  I  believe,  by  the  dental  profession. 
I  suggest,  however,  that  it  is  not  merely  the 
loss  of  calcium,  per  se,  that  is  the  cause,  but 
the  fact  that  in  this  loss  of  lime  the  normal 
stimulus  to  thyroid  activity  is  removed.  As 
to  the  flour.  It  is  now  crushed  between  steel 
rollers,  and  refined  in  such  a  way  that  we  are 
deprived  almost  entirely  of  the  husk  and  germ 
of  the  grain  with  its  valuable  mineral  con- 
stituents. In  the  old-fashioned  way,  part  at 
least  of  this  husk  was  pulverized  between  mill 
stones.  Incidentally,  we  also  lose  the  detritus 
from  the  mill  stones  themselves,  but  I  do  not 
know  whether  it  is  suggested  that  this  loss  is 
a  harmful  one. 

I  do  believe,  however,  that  calcium  salts 
are  the  normal  stimulus  to  thyroid  meta- 
bolism, and  without  this  stimulus  secretion 
may  become  deficient.  In  this  connection 
it  may  be  interesting  to  quote  from  Ringer 
and  Sainsbury's  "Therapeutics,"  a  work  of 
acknowledged  authority  :  "  Experience  has 


I 8  THYROID    THERAPY 

shown  that  lime  water  or  carbonate  of  lime 
is  a  valuable  remedy  in  deficient  nutrition, 
and  in  convalescence  from  various  diseases, 
its  good  effects  being  most  marked  in  children 
suffering  from  rickets,  malnutrition,  &c.  .  .  . 
One  point  may  be  noticed  here,  confirmed 
both  by  theory  and  experience — namely,  that 
small  doses  will  do  as  much  good  as  large 
ones."  Now  the  cases  here  described  corres- 
pond exactly  with  those  of  thyroid  deficiency. 
And  the  small  doses  referred  to  are  sufficient 
to  act  as  a  stimulus  without  overtaxing  thyroid 
activity,  so  benefit  follows.  I  think  that  this 
thyroid-stimulating  action  of  calcium  is  the 
explanation  of  the  fact  (also  quoted  in  Ringer 
and  Sainsbury's  "  Therapeutics  ")  that  "  sac- 
charated  solution  of  lime  does  not  confine  the 
bowels,  but  on  the  contrary  relieves  constipa- 
tion." Lime-water  mixed  with  milk  often 
appears  to  keep  the  bowels  regular  in  infants 
who  otherwise  have  required  aperients.  I  had 
an  adult  patient  who  suffers  from  chronic 
constipation  while  living  in  a  district  supplied 
wholly  with  soft  water,  in  spite  of  the  fact  that 
he  gets  plenty  of  exercise.  If,  however,  he 
goes  to  London,  where  he  takes  less  exercise 
but  drinks  the  hard  water,  his  bowels  are 
regular  at  once ;  and  the  same  thing  occurs 
in  another  district  which  happens  to  be  chalky. 
We  discussed  everything  else  which  could  bear 


THYROID    INSUFFICIENCY  1 9 

on  the  subject,  but  could  find  no  other  reason 
for  this  curious  anomaly.  I  have  had  no 
opportunity  of  investigating  the  matter  further, 
but  may  add  that  he  has  other  stigmata  of 
thyroid  inadequacy  besides  constipation  — 
namely,  hypersensitiveness  to  cold,  and  also 
that  he  is  comparatively  bald,  though  only 
about  36  years  of  age.  On  the  other  hand, 
many  people  become  constipated  at  once  on 
arriving  in  a  hard- water  district.  Here  one 
may  well  suppose  that  the  thyroid  is  not 
in  a  condition  to  respond  to  the  stimulus. 
Perhaps  it  is  already  putting  forth  all  the 
secretion  of  which  it  is  capable  for  the  time 
being.  Obviously,  then,  if  some  be  neutralized 
there  will  be  a  deficiency,  and  some  sign  of 
thyroid  inadequacy  will  occur.  I  favour  the 
above  explanation  on  the  ground  that  it  seems 
highly  improbable  that  the  relatively  small 
amount  of  calcium,  even  continuously  taken  in 
hard  water,  should  cause  constipation  by  acting 
as  an  astringent,  especially  in  view  of  the  fact 
that  the  opposite  results  sometimes  occur.  But 
the  small  amount  of  thyroid  which  we  suppose 
might  thus  be  neutralized  would  otherwise  be 
a  most  potent  agent  in  preventing  constipation. 
So  far  as  this  symptom  is  concerned  I  have 
had  almost  invariably  good  results,  and  have 
only  failed  two  or  three  times  to  cure  constipa- 
tion by  the  administration  of  thyroid.  The 


20  THYROID    THERAPY 

successes  have  been  numerous,  but  do  not 
present  any  special  points  worth  recounting. 
My  most  marked  failure  was  in  a  child  of 
1 8  months,  who  became  obstinately  constipated 
when  cutting  teeth.  The  same  thing  happened 
several  times,  and  though  probably  due  to  thy- 
roid exhaustion,  as  evidenced  in  several  other 
ways,  did  not  respond  to  even  2^  gr.  three  times 
a  day.  Small  doses  were  of  course  tried  first, 
and  one  did  not  care  to  exceed  the  quantity 
named.  One  must  bear  in  mind,  however,  that 
thyroid  is  not  a  purge,  and  will  not  act  as  such. 
The  bowels  must  be  well  opened  at'  first,  and 
then  there  is  every  chance  that  thyroid  will 
keep  them  regular. 

This  preliminary  clearance  is  a  very  impor- 
tant point,  and  was  probably  the  cause  of 
failure  in  the  case  of  the  infant  just  referred  to, 
because  in  her  case  even  large  doses  of 
aperients  were  not  really  effective,  so  possibly 
we  never  gave  the  thyroid  a  fair  chance.  But 
when  the  offending  tooth  was  erupted  constipa- 
tion ceased  to  trouble.  The  cases  most  likely 
to  be  benefited  are  obviously  those  that  show 
some  other  symptoms  of  thyroid  inadequacy, 
and  these  often  give  remarkable  results.  But 
even  in  these  cases,  if  the  administration  of 
thyroid  does  not  correct  constipation  in  a  per- 
fectly satisfactory  manner  within  a  few  days, 
other  measures  must  be  taken  for  a  time.  I 


THYROID    INSUFFICIENCY  21 

feel  pretty  sure  that  the  "  vicious  circle"  plays 
an  important  part  here.  The  endotoxins 
absorbed  from  faecal  accumulations  make  still 
further  demands  on  the  already  insufficient 
thyroid  secretion  and  in  turn  constipation  is 
promoted  by  thyroid  exhaustion. 

Of  course  I  do  not  wish  to  suggest  that 
the  cause  of  constipation  is  always  thyroid 
exhaustion,  though  I  do  believe  that  this  is  the 
case  far  more  often  than  is  generally  supposed. 
And  it  will  not  unfrequently  be  found  that 
thyroid  is  the  most  potent  agent  in  just  those 
cases  which  have  proved  most  refractory  to 
the  ordinary  remedies.  But  as  the  subjects  of 
thyroid  insufficiency,  in  common  with  the  rest 
of  us,  are  subject  to  all  the  other  various  causes 
of  constipation,  it  follows  that  thyroid  cannot 
be  looked  on  as  a  panacea,  though  it  often 
gives  remarkable  results,  and  will  frequently  be 
found  a  useful  adjuvant  in  other  modes  of  treat- 
ment. Such,  for  instance,  was  a  recent  case  of 
syphilis  who  was  taking  i  gr.  each  of  grey 
powder  and  Dover's  powder  five  times  a  day. 
It  was  found  that  the  patient  though  progress- 
ing admirably  in  all  other  ways  was  constipated, 
the  bowels  acting  naturally  about  every  three 
days.  The  patient  was  therefore  allowed 
vegetables,  fruits  and  soups,  which  so  com- 
monly have  to  be  withheld,  but  that  did  not 
improve  the  condition.  But  I  found  that  2  J  gr. 


22  THYROID    THERAPY 


of  thyroid  daily  kept  the  bowels  perfectly 
regular.  The  dose  could  be  omitted  with 
impunity  once  in  four  days,  but  not  oftener. 
It  is  of  importance  to  avoid  setting  up 
diarrhoea  in  a  patient  undergoing  a  course  of 
mercury,  so  the  thyroid  was  really  of  value 
apart  from  the  question  of  how  far  secondary 
syphilitic  symptoms  may  be  adversely  in- 
fluenced by  thyroid  depression.  But  to  return 
to  our  calcium.  We  are  deprived  of  lime  by 
drinking  less  water  than  in  the  days  of  old. 
Doubtless  the  spread  of  the  knowledge  of 
germs  has  contributed  much  to  this  end.  Many 
people  never  drink  unboiled  water  at  all.  It  is 
taken  in  the  form  of  tea,  coffee,  cocoa,  beer  or 
some  other  concoction,  and  most  of  the  calcium 
has  been  precipitated.  Nevertheless,  the  in- 
fluence of  calcium  is  easily  traced  in  those 
districts  where  a  hard-water  supply  prevails, 
particularly  in  the  rural  districts  where  people 
lead  a  less  artificial  life,  and  are  more  likely  to 
drink  the  beverage  provided  by  Nature.  In 
Smale  and  Colyer's  work  on  dental  caries,  we 
find  quoted  the  investigations  of  Rose  re  the 
influence  of  lime  on  caries. 

Briefly,  it  was  found  that  there  was  a  much 
lower  percentage  of  caries  amongst  the  children 
who  lived  in  a  hard- water  district  than  those 
living  only  a  few  miles  away  but  drinking  soft 
water.  Now  I  think  the  influence  of  calcium 


THYROID    INSUFFICIENCY  23 

on  thyroid  activity  is  discernible  in  the  figures 
there  quoted.  Firstly,  there  was  a  group  of 
children  who  had  an  abundant  calcium  supply. 
They  would  be  subject  to  any  beneficial  in- 
fluence of  having  their  thyroids  stimulated 
daily  by  this  calcium,  and  they  had  plenty  of 
calcium  if  able  to  make  use  of  it.  What  do  we 
see  ?  A  percentage  of  diseased  teeth  over 
1 6  and  a  percentage  of  children  affected  by 
caries,  79  in  hard-water  districts  of  Baden, 
82*8  in  those  of  Thuringia.  This  is  a  very 
high  percentage  of  caries,  so  it  follows  that 
neither  the  presence  of  abundant  calcium  nor 
its  stimulating  effect  on  the  thyroid  gland 
were  able  to  act  as  an  efficient  defence  against 
dental  caries.  But  such  a  result  is  not  to  be 
expected,  because  these  children  doubtless 
suffered  from  measles  and  other  complaints 
productive  of  thyroid  exhaustion  and  dental 
caries,  and  some  would  no  doubt  suffer  from 
congenital  thyroid  inadequacy  (without  neces- 
sarily being  cretins),  because  their  parents  had 
goitres,  which  are  always  more  or  less  pre- 
valent in  hard-water  districts.  Others  might 
suffer  from  thyroid  exhaustion  promoted  by 
excess  of  calcium,  and,  again,  rickets  would 
contribute  a  certain  number  of  cases.  So  the 
final  result  is  a  seriously  high  percentage  of 
bad  teeth,  in  spite  of  an  abundant  supply  of 
calcium.  Now  turn  to  the  other  group  of 


24  THYROID    THERAPY 

children.  The  percentage  of  carious  teeth  is 
more  than  double  and  the  percentage  of 
children  affected  was  987  in  soft-water  districts 
of  Baden,  92  in  similar  districts  of  Thuringia. 
In  this  group  the  causes  of  thyroid  depression 
would  operate  in  precisely  the  same  way  as  in 
the  other  group,  with  one  exception — namely, 
that  the  element  of  thyroid  exhaustion  due  to 
over-stimulation  by  calcium  and  inheritance  of 
a  goitrous  parentage  would  be  eliminated.  This 
elimination  would  of  course  affect  the  figures 
favourably  rather  than  otherwise,  decreasing 
the  possible  causes  of  caries.  The  great  in- 
crease of  caries  in  this  group  is  therefore 
rightly  attributed  to  the  absence  of  the  bene- 
ficial influence  of  lime.  But  it  seems  probable 
that  even  in  soft-water  districts  the  ordinary 
food  would  contain  far  more  than  the  small 
amount  of  calcium  required  to  make  good  the 
caries  in  these  defective  teeth,  so  that  the  real 
explanation  is  more  likely  to  be  that  the  caries 
in  these  children  was  due  in  some  measure  to 
a  lessened  efficiency  of  their  thyroid  glands 
caused  by  the  greatly-lessened  supply  of  the 
normal  stimulant  calcium,  which  would  occur 
not  only  in  the  drinking  water  but  also  in 
vegetables  and  fruits  grown  in  the  districts. 
But  an  actual  deficit  of  calcium  is  probably 
impossible,  and  it  seems  probable  that  dental 
caries,  like  rickets,  is  due  to  a  greater  or  less 


THYROID    INSUFFICIENCY  25 

disability  to  absorb  the  calcium  provided,  owing 
to  inefficiency  of  the  thyroid  gland  —  the 
medium  through  which  such  absorption  is  nor- 
mally carried  on.  The  influence  of  calcium  on 
the  thyroid  will  be  further  discussed  in  a  later 
chapter  devoted  specially  to  this  subject.  The 
practical  outcome  of  these  considerations  must 
naturally  be  the  administration  of  thyroid  sub- 
stance to  children  whose  first  teeth  have  been 
unduly  carious,  in  the  hope  that  the  second 
dentition  may  be  favourably  influenced.  So 
far  I  have  only  been  able  to  watch  results  of 
this  procedure  in  two  or  three  cases,  and  as 
far  as  can  be  said  in  so  short  a  time  it  has 
answered  admirably.  But  more  prolonged 
evidence  in  a  larger  number  of  cases  is  neces- 
sary before  one  can  claim  that  the  result  is 
more  than  a  coincidence,  perhaps  dependent 
on  other  factors.  It  may  be  objected  by  some 
that  in  many  cases  the  teeth  are  already  calci- 
fied in  the  gum,  though  not  erupted.  True, 
but  the  teeth  are  still  immature  and  it  is  neces- 
sary for  their  perfect  development  that  there 
should  be  both  an  adequate  supply  of  calcium 
and  also  power  to  absorb  it. 

Another  cause  of  the  increase  in  thyroid 
deficiency,  and  therefore  indirectly  in  the 
increase  of  dental  caries,  may  be  found  I  think 
in  the  lower  birth-rate  and  increasing  disability 
of  mothers  to  suckle  their  infants.  The  grow- 


26  THYROID    THERAPY 

ing"  tendency  of  the  day  is  to  avoid  not  only 
lactation  but  pregnancy.  The  increased  em- 
ployment of  female  labour  and  the  more  arti- 
ficial and  strenuous  existence  of  women  in  the 
higher  social  grades,  coupled  with  increasing 
financial  difficulties,  are  doubtless  in  a  large 
measure  responsible.  As  a  consequence  there 
is  less  demand  for  one  of  the  thyroid  functions. 
For  this  gland  always  enlarges  and  shows 
signs  of  increased  activity  during  pregnancy 
and  lactation.  It  is  a  law  of  Nature  that  an 
organ  not  fully  made  use  of  degenerates. 
A  long  family  is,  I  think,  in  itself  a 
proof  of  thyroid  activity.  As  an  illustration  I 
may  quote  the  case  of  Mrs.  C.  :  She  was 
married  at  the  age  of  twenty,  and  had  seventeen 
pregnancies  in  twenty  years  ;  four  resulted  in 
miscarriages,  and  thirteen  children  were  born 
(no  twins),  of  whom  eleven  are  alive  and  in 
good  health.  She  suckled  all  her  children  and 
had  no  difficulty  in  providing  enough  milk  for 
them  except  with  the  last  three.  Surely,  we 
may  pardon  her  thyroid  for  being  a  little  ex- 
hausted after  such  heroic  efforts.  But  it  has 
quite  recovered  itself  now,  for  Mrs.  C.  is 
64!-  and  is  remarkably  devoid  of  the  various 
stigmata  of  thyroid  insufficiency.  She  has  a 
beautiful  head  of  hair  down  to  her  waist,  thick 
and  only  just  turning  grey.  Her  eyebrows 
also  are  good;  her  bowels  perfectly  regular. 


THYROID    INSUFFICIENCY  27 

She  does  not  like  a  hot-water  bottle  or  many 
clothes  on  the  bed.  She  likes  cold  water  to 
wash  in.  She  prefers  cold  weather  to  hot.  She 
has  no  superfluous  fat.  She  weighs  7  st.  12  lb., 
has  plenty  of  energy  and  does  most  of  her 
own  washing.  She  has  no  skin  troubles,  and 
does  not  suffer  from  chilblains.  She  has  no 
thyroid  enlargement.  Her  neck  is  iif-in. 
round.  She  used  to  have  a  good  set  of  teeth, 
but  broke  many  in  an  accident  when  not  quite 
50  years  of  age.  She  has  ten  left  now,  which 
really  is  not  so  bad  at  644  after  seventeen 
pregnancies.  The  only  thing  she  has  had  any 
real  trouble  with  is  headaches.  But  she  has 
40  of  hypermetropia  in  one  eye  and  30  with 
•50  of  astigmatism  in  the  other,  and  has  only 
worn  spectacles  three  years,  so  we  cannot 
blame  her  thyroid  for  that.  So  far  as  I  have 
been  able  to  ascertain,  Mrs.  C.'s  children  have 
been  endowed  with  special  advantages  which 
one  may  not  unfairly  attribute  to  the  thyroid 
activity  of  their  mother  in  the  first  instance, 
inasmuch  as  she  was  able  to  suckle  them,  and 
later  to  the  fact  that  in  thyroid  matters  they 
had  a  goodly  heritage.  Firstly,  they  all  had 
good  teeth.  This  is  the  mother's  statement, 
and  I  have  not  been  able  to  verify  it.  But  it 
was  given  in  good  faith,  and  must  at  least  be 
taken  to  imply  that  there  was  no  excessive 
dental  caries.  That  the  front  teeth  appeared 


28  THYROID    THERAPY 

sound,  and  the  back  ones  were  not  decayed 
enough  to  cause  toothache  or  dyspepsia  and  so 
draw  attention  to  their  condition.  Secondly, 
they  were  remarkably  free  from  the  ailments  of 
childhood.  Except  perhaps  for  an  occasional 
bottle  of  medicine  administered  for  some 
affection  so  trivial  as  to  escape  recollection, 
they  had  no  medical  attention.  The  mother 
is  quite  definite  about  this.  The  first  doctor's 
bill  she  had  to  pay  was  for  hooping-cough, 
with  which  the  fourth  child  was  affected  at  the 
age  of  10  years.  So  far  as  fertility  goes,  two 
married  daughters  each  have  become  pregnant 
twice  in  roughly  four  years'  married  life,  and 
Mrs.  C.,  has  twelve  grandchildren.  The  evid- 
ence so  far  as  available  is  all  in  favour  of 
thyroid  activity  being  passed  on  to  the  next 
generation.  I  have  omitted  to  mention  that 
none  of  the  children  were  operated  on  for 
enlarged  tonsils  or  adenoids,  nor  did  any  of 
them  suffer  from  nocturnal  enuresis. 

I  have  now  given  three  reasons  for  in- 
creasing prevalence  of  dental  caries,  all  opera- 
ting through  the  thyroid  gland  : — 

(1)  Spread  of  measles  and  other    "minor" 
infectious  complaints  through  increased  educa- 
tion movements. 

(2)  Loss  of  calcium  salts  in  food  and  water, 
operating  partly  per  se,  but  chiefly  by  adverse 
influence  on  thyroid  activity. 


THYROID    INSUFFICIENCY  29 

(3)  Decrease  of  thyroid  activity  due  to  loss 
of  function  entailed  by  evasion  of  maternity  or 
[actation,  or  both. 

The  third  of  these  reasons  may  now  be 
considered  at  length,  particularly  in  its  bearing 
on  rickets,  to  which  I  will  respectfully  draw  the 
attention  of  the  dental  faculty  and  request  them 
for  the  time  being  to  look  at  caries  from  the 
point  of  view  that  dental  caries  is  in  many 
cases  dental  rickets. 


CHAPTER  III. 

Thyroid  a  valuable  Ingredient  of  Mother's  Milk. 

I  HAVE  already  expressed  an  opinion  that 
rickets,  in  its  protean  form,  is  caused  by  de- 
priving the  suckling  of  the  benefits  of  maternal 
thyroid  activity,  which  would,  in  the  natural 
course  of  events,  be  obtained  while  at  the  breast. 
The  same  arguments  apply  in  considerable 
measure  to  dental  caries,  and  the  two  subjects 
are  therefore  interwoven.  Dental  caries  is  far 
less  prevalent  among  savage  races  than  our 
own.  I  have  no  doubt  this  is  due,  at  least  in 
part,  to  the  fact  that  they  nurse  their  children, 
thus  both  helping  to  maintain  the  thyroid 
activity  of  the  race  as  a  whole,  and  conferring 
the  benefits  of  individual  thyroid  activity  on  the 
infants,  while  patent  baby  foods  and  feeding- 
bottles  are  absent,  though  I  suppose  they  are 
making  inroads  like  the  rest  of  civilization.  In 
the  animal  kingdom,  also,  dental  caries  is  the 
exception  rather  than  the  rule,  and  I  suggest 
that  the  reason  here  is  the  same — namely,  that 
they  suckle  their  young.  On  the  other  hand, 
of  course,  the  laws  of  heredity  and  "  the  sur- 
vival of  the  fittest "  have  their  influence — con- 


VALUABLE    INGREDIENT    OF    MOTHER  S  MELK     31 

siderable  among  savage  men,  absolute  among 
savage    beasts.     Any  with  thyroid  deficiency, 
whether  manifested  in  the  form  of  dental  caries, 
or  rickets,  or  any  other  malady,  would  soon  be 
wiped    out.     This    would    apply    especially    to 
the   carnivora,  so  far  as   teeth  are  concerned, 
inasmuch  as  those  with  the  best  teeth  would  be 
victorious  in  the  fights  not  only  for  food  but 
also  for  the  females.     And  amongst  the  herbi- 
vora,   any  with    unsound    teeth  would   not    be 
able  to  graze  in  comfort,  and  would  doubtless 
soon    fall  ill    and  die    off.     Similarly  amongst 
animals,  those  who  become  victims  of  diseases 
such  as    might    be  supposed  to  cause  thyroid 
depression,  and  thus  give  rise  to  dental  caries, 
as  measles  does    in  children,  would  generally 
die  under  natural  conditions,  or  be  killed  off  by 
the  stock-keeper  as  unprofitable  to  keep,  so  one 
could  hardly  expect  often  to  see  dental  caries, 
thus  arising  amongst  them.      It  is  different  with 
the    human   race.     Though  always  striving  to 
better  our  condition,  we  do  much  that  is  harm- 
ful to  the  race  as  a  whole.     Our  poor  efforts  so 
often  result  in  the  preservation  of  the  unfit — for 
a  time  at  least — long  enough  for  them  to  pro- 
pagate their  kind  and  pass  on  their  unfitness  to 
the  next  generation.     Our  business  is  to  trace 
the  origin  of  this  unfitness  if  possible,  and,  as 
far  as  may  be,  strive  to  counteract,  even  if  we 
are  unable  to  eliminate  it. 


32  THYROID    THERAPY 

I   think   it  may  be  fairly  shown,  then,  that 
this  loss  of  breast-feeding  is  a  factor  of  grave 
importance.     So    far   as    dental  caries  is  con- 
cerned,   "  Dr.    Kingston    Barton  found  during 
twenty  years'  experience  that  breast-fed  children 
have  the  best  teeth,  those  fed  on  cow's,  ass's, 
or  goat's  milk  coming  off  next  best,  but  that 
when  starch  or  patent  foods  were  given  in  place 
of  cows'  milk,  the   teeth,  both  deciduous  and 
permanent,    turn    out    badly."     The    nursing 
mothers  have  active  thyroid  glands,  for  it  has 
been  shown   that,   if  thyroid  secretion  be  de- 
ficient or  absent,  a  mother  cannot  continue  to 
suckle  her  child.     Also  the  administration  of 
thyroid  gland  substance  in  such  a  case  promotes 
or  increases  the  flow  of  milk.     Thus  breast-fed 
children  start  in  life  with  an  inherited  tendency 
to  thyroid  activity,  in  spite  of  any  subsequent 
depression   that    may   occur   as  the    result   of 
measles  or  other   complaint.     But  I  have   no 
doubt  that  the  suckling  babe  gets  the  benefit 
of  its  mother's  thyroid  secretion,  acting  through 
the  milk,  during  the  early  months  of  life.      In 
support  of  this  contention  I  will  quote  a  recent 
case.     Mrs.  B.  had    a  much  enlarged  thyroid 
gland,   and  was  nursing  her  baby,  which  was 
well  and  thriving.     But,  having  to  go  out  to 
work,    she   weaned    the    baby   and  put    it   on 
artificial  food.   Shortly  after,  the  child  developed 
urticaria,    of  the    type    known    as    "  urticaria 


VALUABLE    INGREDIENT    OF    MOTHER  S    MILK     33 

chronica  infantum."  So  far  as  one  could  see, 
this  was  not  due  to  digestive  troubles.  The 
child  was  not  sick,  the  bowels  were  regular  and 
the  motions  a  good  colour.  So,  when  looking 
for  a  cause,  it  occurred  to  me  that  perhaps  the 
child  was  missing  the  mother's  thyroid  secre- 
tion. Accordingly  I  administered  J  gr.  of 
thyroid  extract  to  the  baby  twice  a  day,  with 
excellent  results.  The  spots  rapidly  got  well. 
The  mother  accordingly  left  off  giving  the 
powders,  with  the  result  that  a  fresh  crop  of 
spots  appeared.  Administration  of  the  powders 
was  again  effectual,  so  I  think  one  must  accept 
the  inference. 

Since  writing  this  I  have  seen  several  other 
cases  of  this  type  of  urticaria,  accompanied  by 
some  other  symptom  of  thyroid  inadequacy, 
and  thyroid  treatment  was  speedily  successful 
in  all. 

The  protective  influence  of  breast-feeding 
against  rickets  has  been  placed  beyond  dispute. 
It  is  said  that  rickets  is  prone  to  occur  in  the 
younger  members  of  long  families.  If  this  be 
so,  the  fact  is  easily  explained  on  the  ground 
of  thyroid  exhaustion.  If  natural  exhaustion 
were  not  likely  to  result,  there  are  several 
other  factors.  The  children  bring  their  worries 
with  them,  and  a  mother  with  half  a  dozen 
or  more  children  is  sure  to  have  some  inciden- 
tal trouble  or  anxiety,  perhaps  some  illness  or 
3 


34  THYROID    THERAPY 

accident  to  one  of  the  number,  or  worry  as  to 
some  circumstance  affecting  their  welfare,  or 
perhaps  she  has  some  illness  herself.  Any 
factor  such  as  these  may  depress  her  thyroid 
activity  for  a  time,  and  the  result  may  affect 
the  baby  at  the  breast  or  the  infant  yet  unborn. 
The  little  boy  whose  case  I  first  quoted  owed 
his  condition  primarily  to  the  illness  of  his 
father.  For  during  five  months  before  he  was 
born  his  mother  had  great  anxiety  on  that 
account. 

It  often  happens  that  a  mother  is  able  to 
nurse  all  the  earlier  members  of  her  family  at  the 
breast,  but  the  supply  partially  or  wholly  fails 
when  she  has  brought  forth  her  "  quiverful.1' 

I  feel  quite  certain  also  that  deprivation  of 
breast-feeding  has  a  very  material  influence  in 
the  production  of  adenoids  and  enlarged  tonsils, 
and,  in  short,  of  most  of  the  symptoms  of 
minor  thyroid  inadequacy  with  which  one  meets 
in  childhood.  So  far  as  I  have  been  able 
hitherto  to  collect  evidence  on  this  point,  I  find 
that  these  subjects  nearly  all  fall  into  two 
groups.  Those  that  have  had  measles  com- 
prise about  half  the  number,  and  the  majority 
of  the  other  half  prove  to  have  been  bottle-fed. 
Some,  of  course,  come  under  both  these  head- 
ings. It  appears  that  measles  is  about  the 
commonest  and  most  potent  cause  of  thyroid 
inadequacy,  and  I  find  that  where  a  second 


VALUABLE  INGREDIENT  OF  MOTHER  S  MILK  35 

operation  for  removal  of  tonsils  or  adenoids  has 
been  necessary  the  victim  has  not  infrequently 
had  an  attack  of  measles  between  the  two 
operations.  This  is  a  point  of  considerable 
importance  both  for  the  patient  and  the  surgeon. 
If  a  second  operation  is  needed,  the  surgeon 
usually  gets  blamed  for  not  having  done  the 
first  one  properly.  But  this  is  not  necessarily 
the  case  at  all.  It  is  the  business  of  the 
surgeon  to  remove  the  adenoids  and  leave 
behind  the  mucous  membrane,  which  is  the 
natural  lining  of  the  pharynx.  So  long  as  the 
mucous  membrane  remains,  it  is  possible  that 
the  lymphoid  tissue  which  it  contains  may  again 
hypertrophy  and  produce  adenoids.  The  de- 
termining factors  will  be,  on  the  one  hand,  the 
continuance  or  otherwise  of  the  thyroid  insuffi- 
ciency which  first  called  the  adenoids  into 
being,  and,  on  the  other,  the  natural  recupera- 
tive power  of  the  child,  which  enables  it  to 
develop  its  own  resources  when  thyroid  secretion 
is  in  abeyance. 

As  to  tonsils,  it  must  have  occurred  to  every 
surgeon  of  experience  sometimes  to  meet  with 
a  second  enlargement  after  a  technically  perfect 
operation.  Personally,  it  has  fallen  to  my  lot 
to  remove  "enormous  tonsils  twice  from  the 
same  child,  about  a  year  intervening  between 
the  two  operations.  If,  however,  the  first 
operation  be  followed  by  an  adequate  course 


36  THYROID    THERAPY 

of  thyroid,  neither  tonsillar  enlargement  nor 
adenoids  are  likely  to  recur.  But,  leaving 
measles  out  of  the  question,  in  the  other  group 
were  many  children  who  seemed  always  to 
"do  badly,"  though  no  particular  cause  was 
apparent.  These  mostly  proved  to  have  been 
bottle-fed,  and  one  must  assume  that  they 
started  life  without  any  maternal  thyroid  assis- 
tance, and  never  quite  caught  up  in  thyroid 
secretion.  These  cases  are  common  enough, 
and  when  treated  with  thyroid  furnish  most 
gratifying  successes.  They  have  generally 
been  medically  examined,  and  nothing  definite 
has  been  found.  The  parents  have  cherished 
the  hope  that  at  7  or  10,  or  some  other  par- 
ticular age,  the  child  would  get  on. 

It  is  perfectly  astonishing  what  changes  can 
be  wrought  with  a  few  months'  attention  and 
the  use  of  thyroid,  arsenic,  calcium  and  iodides, 
one  or  all  and  in  varied  combination,  the  main 
factor  being  thyroid.  I  have  been  accustomed 
to  weigh  my  cases  as  often  as  possible,  and 
the  steady  increase  of  weight,  the  improved 
appetite,  regularity  of  the  bowels,  disappear- 
ance of  excessive  thirst,  and  general  improve- 
ment in  the  nervous  disposition  of  the  child 
are  a  treat  to  behold.  The  last  such  case  I 
have  seen  at  the  moment  of  writing  has  gained 
7  Ib.  in  four  months  and  a  half.  The  average 
increase  for  his  age  during  that  time  would 


VALUABLE  INGREDIENT  OF  MOTHERS  MILK  37 

have  been  not  quite  2  Ib.  He  is  still  a  trifle 
under  weight  for  his  age,  but  will  soon  catch 
up  if  he  maintains  his  present  progress. 

I  have  just  said  that  dental  caries  is  relatively 
rare  among  uncivilized  races,  and  in  the  animal 
kingdom  as  distinct  from  the  human  race.  The 
same  is  true  of  rickets  and  the  same  arguments 
apply  with  almost  double  force.  Cheadle,  with 
a  vast  experience,  is  only  able  to  quote  one 
case  of  rickets  arising  in  a  child  while  at  the 
breast  during  the  first  ten  months  of  life.  In 
that  particular  case  the  mother  became  preg- 
nant during  lactation,  so  I  suggest  that  the 
unborn  infant  claimed  most  of  her  thyroid 
secretion,  and  did  not  leave  sufficient  surplus 
to  be  excreted  in  the  milk.  The  same  authority, 
in  conjunction  with  Bland  Sutton,  made  some 
most  interesting  observations  among  wild 
animals  at  the  Zoological  Gardens.  The  ob- 
servations may  be  found  in  Clifford  Allbutt's 
"  System  of  Medicine."  Briefly,  the  facts  are 
that  young  animals  deprived  of  their  mother's 
milk  commonly  die  of  acute  rickets.  Many 
litters  of  lion  cubs  have  so  perished  ;  also  young 
bears  and  monkeys.  Rickets  is  also  dreaded 
by  every  breeder  of  large  dogs  if  brought  up 
"  by  hand."  Young  monkeys,  deprived  of  their 
mother's  milk  and  fed  on  vegetable  food — 
chiefly  fruit  —  became  rickety.  Two  young- 
bears  fed  on  rice,  biscuits,  and  raw  meat,  which 


38  THYROID    THERAPY 

latter  they  hardly  touched,  died  of  extreme 
rickets.  Young  lions  fed  on  horse  flesh,  and 
one  additional  meal  per  week  of  lean  goat's 
flesh,  died  of  extreme  rickets ;  and  Cheadle 
also  remarks  that  children  fed  on  oatmeal,  corn- 
flour, bread,  and  patent  foods,  with  little  or  no 
milk,  certainly  become  rickety.  The  evidence 
here  is  conclusive  that  the  essential  cause  of 
rickets  is  deprivation  of  some  ingredient  con- 
tained in  the  mother's  milk.  Now  it  was  found 
possible  to  save  the  young  lions  by  giving  them 
a  diet  of  milk,  pounded  bones,  and  cod  liver 
oil,  in  addition  to  the  raw  meat  diet,  which 
without  such  additions  proved  fatal.  Other  con- 
ditions were  the  same  and  the  cubs  soon  lost 
all  signs  of  rickets  aud  grew  up  strong  and 
healthy.  Cheadle  lays  special  stress  on  the 
influence  of  animal  fat  in  the  prevention  of 
rickets.  He  adduces  as  further  evidence  the 
curative  power  of  cod  liver  oil  in  rickets,  and 
quotes  M.  Remy,  who  states  that  in  Japan, 
where  oils  of  fishes  enter  largely  into  food,  and 
children  are  kept  partly  at  the  breast  up  to  5 
years  of  age,  rickets  appears  to  be  unknown. 

In  view  then  of  the  theory  that  thyroid 
insufficiency  is  the  essential  cause  of  rickets, 
let  us  review  our  facts.  The  young,  when  fed 
on  the  mother's  milk,  do  not  get  rickets. 
During  lactation  there  is  evidence  of  increased 
maternal  thyroid  activity,  and  it  is  only  natural 


VALUABLE    INGREDIENT    OF    MOTHER  S    MILK     39 

to  suppose  that  the  milk  should  in  some  way 
be  the  recipient  of  this  increased  activity.  Fur- 
ther, as  the  milk  is  provided  by  Nature  solely 
for  the  benefit  of  the  young,  it  is  only  natural 
that  this  thyroid-born  ingredient  should  be  not 
only  beneficial,  but  essential  to  health.  Now 
the  human  infant,  if  fed  on  skimmed  milk 
(cow's),  is  apt  to  become  rickety.  The  infer- 
ence is  that  the  thyroid  derivative  is  present 
more  particularly  in  the  cream  or  fat  of  the 
milk.  Human  babies,  under  otherwise  normal 
conditions,  thrive  better  when  breast-fed  than 
when  given  cow's  milk,  however  carefully  the 
latter  be  modified.  But  cow's  milk,  being  so 
much  richer  in  casein  than  human  milk,  is 
generally  diluted  with  twice  its  bulk  of  water 
(lime-water  or  barley  water)  before  the  new- 
born baby  is  able  to  digest  it.  It  follows  that 
any  thyroid  substance  contained  in  the  cow's 
milk  is  thus  diluted  threefold  before  the  babe 
has  a  chance  of  ingesting  it.  When  cream  is 
added  to  this  diluted  milk  the  child  thrives 
better,  probably  because  it  is  getting  a  better 
portion  of  the  thyroid  ingredient.  The  addition 
of  the  cream  also  makes  cow's  milk  more 
closely  resemble  human  milk,  inasmuch  as  the 
latter  is  richer  in  fat,  but  I  suggest  that  the 
value  of  the  fat  is  largely  due  to  its  thyroidal 
content,  inasmuch  as  an  infant  can  easily  manu- 
facture its  own  fat  out  of  carbohydrate  material, 


4O  THYROID    THERAPY 

and  therefore  it  is  difficult  to  see  why  merely 
diminishing  the  supply  of  ready-made  fat  should 
be  fraught  with  such  a  serious  disorder  as 
rickets.  As  to  the  diet  of  the  young  lions, 
they  were  deprived  of  their  mother's  milk  with 
its  thyroid  potentialities  ;  they  died  when  fed 
on  old  horse  meat.  The  old  horse's  thyroid 
was  probably  pretty  well  exhausted,  youth 
being  the  period  of  greatest  thyroid  activity. 
Also  we  must  assume  that  lean  meat  is  at  any 
rate  not  rich  in  this  thyroid  ingredient,  if  it  be 
present  at  all.  The  addition  of  milk,  crushed 
bones  and  cod  liver  oil  was  effective.  The 
potentialities  of  milk  have  already  been  dis- 
cussed. I  do  not  know  whether  the  milk  of  the 
lioness  has  been  analyzed  ;  but  if  it  resembles 
that  of  another  carnivore — the  she-dog — one 
can  readily  suppose  that  cow's  milk  would  be  a 
very  poor  substitute.  Bitches'  milk  contains 
about  three  times  the  quantity  of  casein  and 
more  than  twice  the  fat  found  in  cow's  milk, 
and  attempts  to  bring  up  puppies  from  birth  on 
cow's  milk  usually  end  in  failure.  However, 
even  for  a  lion's  cub,  cow's  milk  is  doubtless 
better  than  no  milk  at  all.  As  to  crushed 
bones,  if  the  thyroid  gland  be  of  paramount 
importance  for  satisfactory  ossification  to  occur, 
it  is  at  least  possible  that  the  bones  may 
actually  contain  some  thyroidal  substance  in  a 
condition  capable  of  being  utilized  by  the  young 


VALUABLE  INGREDIENT  OF  MOTHERS  MILK  41 

animal.  Perhaps  the  essential  lime  salts  in  the 
vitalized  condition  in  which  they  are  contained 
in  fresh  bone  might  be  of  some  nutritive  value 
in  preventing  the  occurrence  of  rickets,  though 
these  same  salts,  it  must  be  observed,  are  com- 
paratively useless  in  this  respect  either  when 
given  in  vegetable  combination  or  crude  chemi- 
cal form.  Lastly,  there  is  cod  liver  oil,  long 
recognized  as  the  best  weapon  we  have  where- 
with to  combat  rickets.  I  cannot  help  thinking 
that  the  iodine  content  of  cod  liver  oil  is  the 
essential  factor  here,  and  able,  in  some  measure 
at  least,  to  replace  the  iodine  content  of  the 
thyroid  gland.  The  same  argument  applies  to 
the  case  of  the  Japanese  children,  who  are 
suckled  late  and  fed  on  fish  oils,  which  are 
almost  certain  to  contain  iodine.  In  treating* 
rickets,  however,  in  the  human  subject  cod  liver 
oil  is  not  always  so  effective  as  it  proved  in  the 
case  of  the  young  lions.  This  is  probably  a 
question  of  digestion.  Many  children  can  only 
tolerate  quite  a  small  and  possibly  insufficient 
dose  to  provide  the  necessary  quantity  of  the 
iodine  ingredient.  In  these  cases,  probably 
thyroid-gland  substance  would  be  more  effica- 
cious, as  it  proved  in  the  case  of  the  child, 
A.  T.,  first  quoted.  If,  as  seems  probable,  the 
cream  or  fat  in  the  mother's  milk  contains  the 
thyroid  ingredient,  deprivation  of  which  causes 
rickets,  it  is  not  to  be  wondered  at  that  this 


42  THYROID    THERAPY 

complaint  and  other  minor  degrees  of  thyroid 
insufficiency  are  so  common  among  the  children 
of  the  poor.  When  cow's  milk  is  diluted  to 
contain  the  same  amount  of  casein  as  human 
milk  (as  is  usually  done,  because  casein  in  excess 
is  not  easily  digested)  the  amount  of  butter  is 
reduced  to  127  per  1,000,  instead  of  43*43, 
which  is  the  proportion  in  human  milk.  This 
is  a  shortage  of  approximately  a  teaspoonful  of 
cream  to  every  4  oz.  of  the  diluted  cows'  milk. 
If  asses'  milk,  proportionately  diluted,  were 
used,  the  shortage  of  cream  would  be  only  half 
that  amount.  Now,  amongst  the  poor  one  may 
say  that  cream  is  very  rarely  added  to  the  milk 
prepared  for  babies'  food  ;  only  too  often  it  is 
the  ether  way  and  skimmed  milk  is  given.  Also 
the  standard  amount  of  cream  in  milk  recog- 
nized by  law  is  lower  than  that  commonly 
present  in  good  cow's  milk,  which  still  further 
enhances  the  evil.  The  common  substitute  of 
margarine  for  butter  amongst  the  children  of 
the  poor  is  another  factor  which  must  not  be 
lost  sight  of.  Margarine  is  a  mixture  prepared 
from  beef  fat  and  vegetable  oils,  such  as  cotton- 
seed oil  and  cocoa-nut  oil.  It  is  extremely 
unlikely  that  any  thyroid  ingredient  is  present 
in  this  beef  fat. 

To  sum  up  our  conclusions  then  :  Rickets  is 
due  to  the  lack  of  a  thyroid  ingredient  which  in 
the  first  months  of  life  is  obtained  from  the  milk 


VALUABLE  INGREDIENT  OF  MOTHER'S  MILK  43 

of  nursing  mothers,  the  cream  probably  con- 
taining the  chief  portion  of  this  ingredient. 
We  may  reasonably  infer  that  a  similar  ingre- 
dient is  contained  in  the  milk  of  the  cow  and 
other  animals,  which  may  be  successfully  sub- 
stituted for  the  mothers'  natural  milk  if  due 
regard  be  paid  to  the  proportion  of  cream. 
Further,  that  cod  liver  oil  is  able  in  some 
measure  to  take  the  place  of  this  ingredient,  a 
fact  which  at  least  suggests  the  possibility  of 
the  iodine  radical  present  both  in  cod  liver  oil 
and  also  in  thyroid  gland  being  the  essential 
factor.  Thus  far  we  have  looked  on  rickets  as 
of  maternal  origin — that  is,  due  to  deprivation 
of  thyroidal  products,  which  would  in  the  natural 
course  of  things  be  provided  by  the  mother. 
It  is  at  any  rate  evident  that  the  thyroid  gland 
of  the  newly-born  animal  is  not  capable  of 
sufficient  activity  to  save  its  .possessor  from 
rickets  in  the  absence  of  any  other  source  of 
supply,  and  it  is  also  evident  that  if  the  thyroid 
gland  of  the  infant  be  still  unequal  to  its  duties 
when  the  period  of  suckling  is  terminated,  and 
sufficient  subsidiary  help  be  not  forthcoming, 
rickets  will  still  occur,  though  not  in  so  severe 
a  form  as  that  arising  at  the  earlier  date.  This 
is  where  the  food  factor  is  of  so  much  import- 
ance. Milk  with  its  cream  as  supplying  the 
thyroid  factor  should  still  be  a  staple  article  of 
diet ;  but  now  the  child  should  be  able  to  digest 


44  THYROID    THERAPY 

undiluted  cow's  milk,  which  will  lessen  the  evil 
of  fat  deficiency,  though  the  quantity  will  still 
be  below  the  standard.  Butter  will  also  enter 
into  the  dietary,  and,  in  the  absence  of  thyroid 
depression  from  some  debilitating  influence,  the 
child  should  now  go  on  all  right.  It  has  become 
a  much  more  general  custom  to  boil  milk  nowa- 
days for  infant  feeding.  This  is  very  good  from 
the  sterilization  point  of  view,  but  there  is  no 
doubt  that  the  milk  is  damaged  in  the  process, 
partly  of  course  by  the  injurious  effect  of  heat 
upon  the  contained  lecithin,  and  also  because, 
as  has  recently  been  shown,  cow's  milk  con- 
tains a  very  valuable  ingredient  in  the  form  of 
lactalbumin  which  would  probably  be  much 
damaged  in  boiling.  The  importance  of  lact- 
albumin consists  in  the  fact  that  it  is  far  more 
abundant  in  human  milk  than  in  that  of  the 
cow,  and  that  it  exerts  a  material  influence  in 
rendering  the  curds  of  human  milk  more  floccu- 
lent  and  so  more  easily  digestible  than  those 
of  cow's  milk.  Possibly  the  thyroid  ingredient 
of  milk  may  also  be  damaged  by  boiling. 


45 


CHAPTER  IV. 

Fat  and  Thyroid  Activity. 

THERE  is  another  factor  which  must  not  be 
lost  sight  of  in  the  interpretation  of  the  facts 
discussed  in  the  last  chapter,  and  that  is  the 
effect  of  fat  on  thyroid  activity.  The  con- 
verse proposition  has  received  considerable 
attention,  and  thyroid  has  been  widely  used 
as  a  fat  reducer.  It  is,  however,  falling  into 
disfavour,  as  experience  shows  that  in  many 
cases  there  occurs  no  reduction  of  fat  ap- 
preciable from  the  cosmetic  standpoint,  so 
long  as  ordinary  and  safe  doses  of  the  drug 
are  taken.  The  Editor  of  the  Medical  Review 
(October,  1910)  points  out  that  the  effect  of 
thyroid  feeding  is  to  dehydrate  the  fats  of  the 
body  temporarily,  the  utmost  results  so  obtain- 
able occurring  by  the  end  of  a  week,  but  that 
excessive  administration  of  thyroid  may  pro- 
duce glycosuria,  and  there  is  already  a  latent 
tendency  to  glycosuria  in  many  sufferers  from 
obesity.  1  have  administered  2  J  gr.  of  thyroid 
three  times  a  day  for  several  months  to  a  fat 
old  woman  with  rheumatoid  arthritis ;  the 
disease  improved  a  great  deal,  but  there  was 


46  THYROID    THERAPY 

no  visible  diminution  in  the  fat.  Nevertheless 
where  increase  of  fat  is  accompanied  by  or 
due  to  thyroid  deficiency,  good  results  may 
sometimes  be  obtained,  and  have  been  reported 
from  time  to  time,  by  thyroid  medication. 

I  have  such  a  case  now  under  treatment. 
She  is  a  woman  of  32,  and  probably  an  exam- 
ple of  the  rare  complaint  described  as  "adiposis 
dolorosa."  Her  fat  is  massed  particularly 
round  the  hips,  and  in  this  region  she  com- 
plained of  pain,  and  was  acutely  sensitive  to 
digital  pressure.  Her  shins  were  also  found 
to  be  very  tender,  which  might  suggest  alco- 
holic neuritis.  But  this  is  not  the  case.  She 
complained  chiefly  of  pain  over  the  sacrum  and 
iliac  crest,  and  of  frequent  and  precipitate 
micturition.  No  other  cause  being  found,  she 
was  put  on  thyroid  treatment,  which  speedily 
relieved  all  her  symptoms  and  decreased  her 
weight  by  9J  Ib.  in  six  weeks.  She  still 
weighs  i2st.  2 Jib.,  and  tenderness  can  be 
elicited  by  pressure  on  the  previously  painful 
parts.  Naturally  she  is  continuing  her  treat- 
ment. Her  diet  has  not  been  much  altered, 
the  chief  item  being  the  substitution  of  jam  or 
marmalade  for  butter. 

There  are  various  points  suggestive  of  some 
natural  inter  -  dependence  between  fat  and 
thyroid  activity.  Rickety  children  are  com- 
monly fat,  as  though  Nature  attempted  in  some 


FAT    AND    THYROID    ACTIVITY  47 

way  to  compensate  for  the  lack  of  thyroid  by 
the  addition  of  fat.  Contrast  this  fatness  with 
the  thinness  of  Graves's  disease.  Another  point 
is  suggested  by  the  fact  that  two  of  the  common 
symptoms  of  thyroid  inadequacy  are  sensitive- 
ness to  cold  and  loss  or  scantiness  of  hair. 
In  treating  myxcedema,  which  represents,  of 
course,  total  thyroid  inactivity,  great  care  has 
to  be  taken  to  protect  the  sufferers  from  cold. 
They  are  always  worse  if  exposed  to  cold, 
and  are  often  sent  to  warm  climates  on  this 
account,  though  the  thickened  and  sensitive 
skin  seems  to  prevent  them  from  having  a 
subjective  sensation  of  cold.  Conversely  the 
subjects  of  Graves's  disease  do  not  suffer  from 
cold,  but  experience  a  constant  and  often  un- 
pleasant sensation  of  heat.  Now,  those  races 
who  are  habitually  exposed  to  great  cold — the 
Esquimaux,  for  example — eat  enormous  quanti- 
ties of  fat,  and  the  animals  living  in  cold  regions 
are  provided  by  Nature  not  only  with  much 
fat,  but  also  with  most  luxuriant  hair  or  fur. 
Fur  and  fat  are,  of  course,  both  bad  con- 
ductors of  heat,  and  so  serve  to  protect  their 
possessors  from  undue  loss  of  heat.  Doubtless 
the  fat  which  is  eaten  helps  by  combustion  to 
produce  this  heat.  But  it  probably  also  assists 
by  stimulating  thyroid  activity.  We  have 
already  seen  that  thyroid  deficiency  is  a  factor 
in  the  production  of  baldness  or  loss  of  hair, 


48  THYROID    THERAPY 

and  naturally  must  assume  that  the  converse 
holds  good  in  some  degree.  The  Esquimaux 
show  further  evidence  of  thyroid  activity  by 
being  remarkably  free  from  dental  caries. 
There  is,  however,  another  factor,  which  would 
promote  thyroid  activity,  and  that  is  the  iodine 
present  in  the  fish  food  and  possibly  also  in 
the  fat  of  seals  and  other  creatures  which  live 
upon  fish.  Possibly,  we  do  not  take  enough 
notice  of  the  natural  likes  and  dislikes  of 
people.  Too  often  we  are  content  to  pass 
them  over  as  idiosyncrasies  without  any  inquiry 
as  to  whether  they  are  not  merely  the  outcome 
of  some  underlying  law  of  Nature.  But  there 
is  a  natural  instinct  common  to  animals  which 
tells  them  when  to  eat  and  when  to  abstain, 
and  also  what  to  eat  and  what  to  avoid.  The 
same  instinct  is  to  be  found  in  the  human  race, 
though  unfortunately  often  dormant,  stamped 
out  by  our  vaunted  superior  knowledge,  and 
various  ideas  often  foolishly  passed  on  from 
one  generation  to  another.  As  a  simple 
instance  of  the  kind  I  mean  is  the  craving  for 
cold  water  experienced  by  many  patients  with 
fever.  It  is  by  far  the  most  cooling  and  re- 
freshing drink  and  provides  the  material  for 
the  beneficial  sweating  which  is  to  follow,  not 
to  mention  helping  to  flush  the  kidneys  and 
wash  away  toxins  and  also  correcting  the 
tendency  to  constipation.  But  unfortunately 


FAT    AND    THYROID    ACTIVITY  49 

everyone  except  the  patient  has  a  horror  of 
such  a  thing.  It  will  give  a  chill,  or  upset  the 
stomach,  and  so  forth.  Possibly  if  it  has  been 
long  withheld  artificially,  the  patient  might 
take  too  much  at  first  on  having  his  wish 
granted.  But  had  he  been  allowed  to  follow 
his  instinct  from  the  first,  he  would  probably 
have  gently  sipped  all  he  wanted,  and  been 
much  more  comfortable  throughout  the  disease. 
I  do  not  say  that  scientific  reasoning  is  not 
superior  to  instinct,  for  it  obviously  is,  but  I 
do  think  there  is  often  much  to  be  learned 
from  the  natural  instincts  of  the  individual,  if 
we  only  look  for  it.  As  another  instance,  A. 
Siegmund  looks  on  distaste  for  meat  as  a 
certain  sign  of  congenital  or  acquired  thyroid 
deficiency.  Apparently  then  "Jack  Spratt's  " 
wife  who  "could  eat  no  lean"  was  the  subject 
of  thyroid  deficiency.  But  it  is  equally  evident 
that  Jack  Spratt,  who  could  eat  no  fat,  was  the 
possessor  of  an  active  thyroid,  and  probably 
was  constantly  complaining  that  the  fire  was 
too  big,  and  wanting  the  doors  and  windows 
open.  He  was  not  necessarily  the  victim  of 
Graves's  disease,  though  he  might  have  been. 
These  inferences  can  all  be  correctly  made  in 
the  case  of  the  four  individuals  who  daily  feed 
at  my  dinner-table,  but  of  course  it  does  not 
follow  that  there  are  no  exceptions  to  the  rule, 
and  thyroid  deficients  will  often  be  found  who 
4 


50  THYROID    THERAPY 

do  not  like  meat  fat,  but  are  extra  fond  of  butter. 
The  dislike  of  fat  commonly  shown  by  those 
who  have  active  thyroids  is  open  to  two 
explanations.  First,  because  of  its  heating 
propensities,  secondly,  because  the  thyroid 
secretion  is  antagonistic  to  that  of  the  pancreas 
(W.  Falta).  It  is  therefore  probable  that 
antipathy  to  fat  is  sometimes  caused  by  dis- 
ability to  digest  it.  The  disability  is  an  un- 
conscious one,  and  in  the  presence  of  others 
enjoying  the  indigestible  article  the  natural 
instinct  may  be  obliterated,  and  the  offence 
committed.  Not  infrequently  the  immediate 
result  is  vomiting.  I  recently  came  across  a 
patient  suffering  from  simple  thyroid  enlarge- 
ment, who  volunteered  the  statement  that  she 
habitually  vomited  "  anything  greasy."  The 
vomiting  had  been  an  almost  daily  occurrence 
for  a  year,  at  the  end  of  which  time  she  had  a 
very  large  goitre  (girth  14^-  ins.).  When  she 
came  to  me  I  prescribed  thyroid,  and  the 
vomiting  immediately  ceased,  while  the  goitre 
diminished.  During  the  course  of  treatment 
however,  shortly  after  a  monthly  period,  her 
thyroid  gland  became  larger  and  the  vomiting 
returned.  The  vomiting  was  sudden,  painless, 
and  not  preceded  by  nausea.  It  was  again 
remedied  by  taking  thyroid,  and  later  when  she 
left  off  medicine  for  a  fortnight  she  vomited 
every  day  of  the  second  week.  Now  the 


FAT    AND    THYROID    ACTIVITY  51 

evidence  here  is  somewhat  mixed.  The 
simplest  explanation  is  to  leave  the  pancreas 
out  of  the  question,  and  to  say  that  the  vomiting 
only  occurred  with  those  things  which  would 
ordinarily  be  likely  to  upset  a  sensitive  stomach, 
namely,  the  "greasy"  things  ;  that  the  vomit- 
ing was  analogous  to  the  vomiting  of  pregnancy 
which  has  shown  itself  amenable  to  thyroid 
treatment,  and  commonly  occurs  in  the  early 
months  of  pregnancy,  before  the  thyroid  has 
had  time  to  hypertrophy  and  assume  the  con- 
dition of  hyper-activity  normal  to  pregnancy. 
Why  a  pregnant  woman  should  vomit  in  the 
absence  of  adequate  thyroid  secretion  is  another 
problem  altogether.  Is  it  due  to  toxins  of 
foetal  or  genital  origin  which  are  eliminated  by 
an  active  thyroid  ?  But  this  girl  was  not 
pregnant.  She  was,  however,  at  an  age  of 
special  uterine  and  ovarian  development,  a 
period  which,  as  is  commonly  agreed,  makes 
special  demands  on  the  thyroid.  That  the 
vomiting  was  due  to  thyroid  insufficiency  was 
proved  by  the  fact  that  it  was  cured  by  thyroid 
and  only  recurred  when  she  ceased  to  take 
thyroid  and  during  a  menstrual  period  when 
the  supply  of  thyroid  once  more  proved  in- 
adequate. The  vomiting  of  pregnancy  is  not 
due  to  fats  apparently,  as  in  bad  cases  all  foods 
alike  are  rejected.  And  it  is  not  caused  by 
thyroid  inadequacy  in  itself  (but  by  some  factor 


52  THYROID    THERAPY 

removable  by  thyroid  efficiency),  because  vomit- 
ing is  not  a  common  accompaniment  of  thyroid 
inadequacy  apart  from  pregnancy.  Vomiting 
is,  however,  a  common  symptom  of  Graves's 
disease,  and  in  some  such  cases,  may  well  be 
co-related  to  the  failure  in  digestion  of  fats 
owing  to  pancreatic  insufficiency.  W.  Falta 
(quoted  in  Medical  Review,  November,  1910) 
states  that  thyroid  hyper -activity  diminishes 
pancreatic  activity,  and  relates  experiments 
showing  that  the  inability  to  absorb  fats  de- 
pends on  inhibition  of  the  internal  pancreatic 
secretion,  not  the  external.  Next  arises  the 
question,  Is  this  pancreatic  inhibition  in 
Graves's  disease  beneficial  and  protective,  or 
otherwise  "  ?  I  cannot  answer  the  question 
at  present,  for  though  the  administration  of 
"  Holadin  "  (a  preparation  specially  stated  to 
contain  all  pancreatic  extracts  and  ferment) 
speedily  caused  a  complete  alteration  in  the 
"  fatty  "  appearance  of  the  stools  of  my  patient, 
in  other  respects  she  was  perhaps  not  quite  so 
well  after  taking  this  preparation  for  a  fortnight. 
Now  if  we  pursue  these  conclusions  to  a  logical 
sequence,  they  are  bound  to  influence  our 
treatment  of  Graves's  disease  with  at  least  some 
benefit.  To  reiterate  briefly,  I  have  endeav- 
oured to  show  in  this  chapter  and  the  last : 

i.  That  milk,   probably  cream,    and   there- 
fore presumably  butter,  contain  an  appreciable 


FAT    AND    THYROID    ACTIVITY  53 

quantity  of  thyroid  substance,  at  any  rate 
enough  to  save  from  rickets  the  infant  whose 
own  thyroid  unaided  is  quite  insufficient. 

2.  That  probably  fat  has  a  stimulating- 
effect  on  the  thyroid. 

I  may  now  relate  the  results  of  treating 
Graves's  disease  on  these  lines  so  far  as  my 
limited  observations  have  carried  me.  The 
subject  of  the  following  remarks  had  been 
treated  for  some  fifteen  months  both  by  myself 
and  others  with  varying  success.  She  had  just 
returned  home  from  hospital  after  seventeen 
weeks  in  bed  under  open-air  treatment  and 
was  certainly  better,  though  far  from  well.  She 
still  had  a  pulse-rate  of  1 20  or  more,  frequent 
palpitation,  grossly  exaggerated  knee-jerks, 
tremors  and  a  general  sense  of  disability  for 
exertion.  On  her  return  from  the  hospital  I 
began  treating  her  with  thymus  2^-  gr.  three 
times  a  day,  and  she  continued  to  rest  as  pre- 
viously. Both  the  patient  and  I  thought  she 
was  improving  slightly,  though  not  a  great 
deal.  But  one  day  after  about  a  fortnight  of 
this  treatment  she  had  some  pork  sausage  for 
breakfast  and  within  half  an  hour  was  taken 
with  violent  palpitation  which  lasted  all  day. 
I  did  not,  however,  see  her'  until  the  evening, 
when  she  was  rather  better,  but  still  very  un- 
comfortable with  a  pulse-rate  of  150  to  the 
minute.  The  question  arose,  what  could  have 


54  THYROID    THERAPY 

brought  about  this  attack  ?  Pork  sausage,  or 
bacon,  or  eggs  for  breakfast  had  on  several 
occasions  previously  been  responsible,  but 
latterly  she  had  been  better  and  able  to  indulge 
with  impunity.  However,  on  going  into  the 
matter  carefully  it  transpired  that  she  had  been 
having  extra  cream,  milk  and  butter  all  the 
week,  fish  on  two  occasions,  and  chitterlings 
(pig's  intestine)  on  the  night  before.  She  had 
not  been  conscious  of  any  gastric  disturbance 
and  normally  her  appetite  was  healthy  and 
bowels  regular,  generally  twice  a  day.  Her 
sister  with  whom  she  was  staying,  however, 
had  received  a  present  of  some  cream  and 
bestowed  the  luxury  on  the  invalid,  which  was 
so  much  appreciated  that  she  subsequently  had 
skimmed  the  household  milk  to  obtain  still 
further  cream.  Now  the  result  is  open  to  the 
interpretation  that  the  attack  was  produced  by 
giving  these  substances  rich  in  products  of 
thyroid  activity  to  a  patient  who  was  already 
suffering  from  thyroidal  excess.  Some  no 
doubt  will  say  it  was  reflex — the  result  of 
gastric  irritation  from  the  sausage.  Perhaps 
it  was,  but  she  had  no  gastric  discomfort, 
furred  tongue  or  any  of  the  other  symptoms 
that  go  by  the  name  of  ''indigestion."  So, 
acting  on  the  first  hypothesis,  I  put  her  on 
the  very  diet  which  would  cause  rickets  in  a 
child.  I  forbade  cream,  milk,  butter  or  any 


FAT   AND    THYROID    ACTIVITY  55 

animal  food  whatever.  She  was  to  live  for  the 
time  being  entirely  on  vegetable  food,  largely 
farinaceous.  I  did  not  even  at  first  allow  lean 
meat,  because  although  that  did  not  save  the 
young  lions  from  rickets  in  the  experiments 
already  quoted,  there  is  possibly  a  difference  in 
the  thyroidal  ingredient,  absent  apparently  from 
old  horse-flesh,  perhaps  present  in  the  meat  of 
such  younger  animals  as  are  killed  for  human 
food.  I  forbade  eggs,  because  it  is  only  logical 
to  suppose  that  they  represent  in  some  way 
the  thyroidal  activity  of  the  fowl.  The  yolk  is 
the  food  specially  designed  for  the  young  chick 
and  is  rich  in  fat  and  perhaps  analogous  to 
cream  in  thyroidal  content.  The  patient  had 
been  taking  thymus  at  the  rate  of  7^  gr.  a 
day  for  the  fortnight  preceding  the  bad  attack, 
and  this  was  at  first  continued  during  the 
period  of  abstinence  from  fat.  The  thymus 
appeared  to  be  exerting  a  favourable  influence 
on  the  symptoms,  but  as  has  been  seen  did  not 
prevent  the  sudden  and  serious  relapse.  Now 
abstinence  from  fat  appeared  immediately  to 
exert  a  more  markedly  beneficial  influence  than 
any  treatment  had  done  previously.  The 
pulse  in  a  few  days  dropped  to  95  while 
the  patient  was  up  and  dressed,  though  leading 
an  invalid  life.  Previously  96  was  the  lowest 
that  had  been  registered  for  months  and  that 
only  during  continued  rest  in  bed.  When 


56  THYROID    THERAPY 

up  the  frequency  was  always  no  and  often 
1 20.  She  now  improved  at  a  more  rapid  rate 
than  at  any  time  previously  during  the  illness. 
Within  a  fortnight  she  was  able  to  take  a  walk 
of  one  and  a  half  miles,  more  than  she  had  done 
for  fifteen  months  previously,  and  the  day  after 
her  pulse  was  only  105.  Further,  the  diet 
suited  her  general  health  and  she  gained  5^  Ibs. 
weight  in  twenty-four  days.  The  bowels  were 
open  two  or  three  times  a  day  but  were  not 
loose  and  there  was  no  gastric  disturbance.  She 
then  unfortunately  took  influenza  in  common 
with  the  other  members  of  the  household  and 
naturally  her  condition  did  not  improve.  At 
the  time  of  writing,  however,  she  has  stuck  to 
her  diet  for  two  and  a  half  months  and  thrives 
on  it,  though  deprivation  of  butter  appears  to 
be  a  hardship.  Olive  oil  takes  the  place  of 
butter,  dripping,  or  lard,  in  cooking.  Later  I 
found  it  necessary  to  allow  lean  meat  as  a 
relish  for  bread.  The  patient  has  improved 
greatly  in  her  capacity  for  taking  physical 
exercise  and  is  able  to  carry  out  her  domestic 
duties  to  a  much  greater  extent  than  formerly, 
and  can  walk  about  two  and  a  half  miles  with- 
out feeling  any  the  worse  for  it.  Nor  has  she 
had  any  recurrence  of  the  bad  attacks  of 
palpitation.  So  far  as  it  goes  then  the  treat- 
ment is  obviously  beneficial,  but  it  is  equally 
obvious  that  one  cannot  expect  to  suppress 


FAT   AND    THYROID    ACTIVITY  57 

excessive  thyroid  activity  by  the  mere  removal 
of  what  may  be  regarded  as  thyroidal  adjuvants. 
Another  patient,  who  had  been  immensely 
benefited  by  ligature  of  her  superior  thyroid 
arteries  on  both  sides  some  four  years  previously, 
reported  immediate  and  considerable  further 
improvement  on  abstaining  from  milk  and 
butter.  In  this  case,  however,  the  patient,  who 
weighed  10  st.  9!  Ib.  in  indoor  clothes,  lost 
6  Ib.  in  weight  in  a  fortnight,  and  this  may 
have  caused  the  improvement,  which  consisted 
in  lessened  sense  of  fatigue  with  increased 
capacity  for  exertion.  She  lost  i  Ib.  more  in 
the  following  month  and  maintained  the  im- 
provement in  health.  The  loss  of  weight  was 
probably  due  to  eating  less  bread,  as  jam, 
honey,  &c.,  proved  less  palatable  than  butter. 
The  pulse-rate  was  about  100  all  the  time,  but 
the  patient  thought  she  was  less  nervous  and 
obtained  greater  freedom  from  headaches.  This 
patient's  normal  pulse-rate  had  been  about  100 
for  some  twelve  months,  but  was  subsequently 
reduced  to  80  by  a  course  of  salicylates  and 
cinchona,  the  influence  of  which  drugs  is 
discussed  in  a  later  chapter. 


CHAPTER  V. 
Goitre — Calcium  and  the  Thyroid  Gland. 

THE  influence  of  calcium  on  thyroid  activity 
naturally  involves  the  consideration  of  goitre. 
Various  views  have  been  held  as  to  the  path- 
ology of  goitre.  When  I  was  a  student  I  was 
taught  that  goitre  was  probably  due  to  some 
germ  flourishing  in  chalky  districts.  Accord- 
ingly, when  I  happened  to  live  in  such  a 
district,  I  began  making  inquiries  on  my  own 
account  and  questioned  a  good  number  of  in- 
dividuals suffering  from  goitre.  I  soon  found 
that  many  of  them  never  drank  cold  water  at 
all.  Whatever  fluid  they  drank  had  been 
boiled  and  therefore  sterilized,  whether  taken 
in  the  form  of  tea,  or  beer,  or  any  other  fluid 
commonly  imbibed.  Nevertheless,  they  still 
had  goitres.  Now  calcium  carbonate  is,  of 
course,  precipitated  by  boiling,  so  it  might  be 
argued  that  the  goitres  were  not  due  to  exces- 
sive ingestion  of  calcium.  This  difficulty  is, 
however,  easily  disposed  of.  Some  of  the 
calcium  remains  as  ''fur"  on  the  inside  of  the 
kettle.  But  particles  are  so  constantly  rubbed 


GOITRE  59 

off  that  there  is  invariably  a  considerable 
quantity  of  calcium  in  suspension  in  the  water, 
instead  of  being  in  solution.  The  stream  of 
water  from  the  tap,  when  the  kettle  is  filled,  is 
quite  sufficient  to  loosen  a  large  number  of 
particles  of  "fur,"  and  anyone  who  looks  in- 
side the  kettle  will  see  plenty  of  loose  fragments, 
which  have  a  happy  knack  of  remaining  in  the 
kettle,  clinging  to  the  roughened  inner  surface, 
even  when  one  endeavours  to  wash  them  out. 
The  boiling  of  the  water  then  agitates  all  these 
particles  and,  as  I  have  often  noticed,  many 
find  their  way  in  powdered  condition  to  the 
teapot,  and  in  due  course  to  the  stomachs  of 
the  tea-drinkers.  Calcium  sulphate,  if  present, 
remains  in  solution.  Similarly  in  cooking, 
calcium,  though  precipitated,  may  be  served  up 
intimately  mixed  with  vegetables  and  other 
food.  Thus,  although  boiling  exerts  a  material 
influence  on  the  amount  of  lime  ingested,  there 
still  remains  a  quantity  which  may  very  well  be 
the  cause  of  goitre.  I  see  no  reason  for  sup- 
posing the  presence  of  any  rarer  metal  in 
combination  with  the  calcium,  though  such  may 
be  the  case.  It  is  also  more  than  likely  that 
vegetables  and  fruit  grown  in  a  limestone 
district  contain  a  higher  percentage  of  calcium 
than  those  grown  elsewhere.  Also  that  the 
cattle  living  in  such  a  district  get  more  lime 
into  their  systems,  both  from  grazing  and 


6O  THYROID    THERAPY 

drinking  hard  water.  If  the  cattle  are  pos- 
sessed of  active  thyroids,  they  will  assimilate 
lime  to  the  full,  and  their  milk  will  be  rich  in 
calcium.  On  the  other  hand,  if  their  thyroid 
glands  should  be  at  all  exhausted  by  dealing 
with  so  much  calcium,  the  milk  will  be  poorer 
in  thyroidal  substances.  Thus,  whether  we 
eat  meat  or  drink  milk,  or  water,  or  consume 
vegetables,  or  fruit,  in  such  a  district  our 
thyroid  glands  will  be  worked  at  higher  pressure 
than  if  we  lived  in  a  soft-water  district.  The 
result  will  depend  on  how  far  an  even  balance 
be  struck  between  thyroid  capacity  and  the 
work  required.  If  excess  of  work  be  demanded 
for  a  considerable  time,  it  is  only  natural  that 
hypertrophy  should  result.  The  commonest 
form  of  goitre  is  simple  hypertrophy,  and  pro- 
bably most,  if  not  all,  goitres  start  in  this  way. 
It  may  be  objected  that  other  glands  in  the 
body  do  not  hypertrophy  to  any  extent  as  the 
result  of  over-work,  and  why  should  the  thyroid 
be  an  exception  ?  But  the  case  of  thyroid 
hypertrophy  is  not  quite  on  a  parallel,  as  there 
is  clearly  some  toxic  agent  at  work.  The 
spleen  enlarges  in  typhoid  fever,  and  to  a  much 
greater  extent  in  malaria.  Lymphatic  glands 
enlarge  in  the  neighbourhood  of  a  septic  wound. 
In  these  cases  the  toxin  is  clearly  of  microbic 
origin,  though  the  actual  irritant  is  presumably 
some  chemical  product  of  their  activity. 


GOITRE  6 1 

In  the  case  of  goitre  the  irritant  which  causes 
enlargement  is  chemical,  and  I  see  no  reason 
why  it  should  be  anything  else  than  some  form 
of  calcium.  But  the  precise  method  in  which 
calcium  acts  needs  elucidation.  It  is  not  diffi- 
cult to  explain  the  addition  of  an  adenoma  to 
the  hypertrophy.  It  is  supposed  that  adeno- 
mata are  developed  from  small  isolated  portions 
of  the  gland  called  rests.  These  "rests,"  of 
course,  get  the  benefit  of  the  increased  blood- 
supply,  and  are  therefore  extremely  likely  to 
share  in  the  general  hypertrophy.  Other 
morbid  changes  doubtless  occur  as  the  result 
of  irritation,  inflammation,  or  degeneration. 
As  to  the  manner  in  which  calcium  acts  as  a 
stimulant  to  thyroid  activity,  I  think  it  is  largely 
a  question  of  antagonism,  a  dose  of  calcium 
calling  for  thyroid  secretion  in  much  the  same 
way  as  a  dose  of  carbonate  of  soda  calls  forth 
the  acid  secretion  of  the  stomach.  The  analogy 
may  be  pressed  further.  If  the  dose  of  sodium 
bicarbonate  be  excessive,  the  stomach  may  not 
be  able  adequately  to  respond,  and  the  con- 
tents may  remain  alkaline  for  some  time, 
though  in  the  absence  of  pathological  con- 
ditions the  acid-secreting  cells  soon  gain  the 
upper  hand.  So  with  the  thyroid.  Small 
doses  of  calcium  use  up  the  available  secretion, 
and  the  natural  result  is  that  the  thyroid  sets 
to  work  to  make  more.  If  the  dose  be  repeated 


62  THYROID    THERAPY 

too  frequently  a  period  of  exhaustion  will 
follow.  The  exhaustion  may  be  of  short  dura- 
tion and  the  thyroid  may  quickly  regain  the 
upper  hand.  But  if  the  exhaustion  be  pro- 
longed, Nature  sets  to  work  to  remedy  the 
defect  by  installing  more  powerful  machinery, 
in  other  words,  enlarging  the  gland,  or  possibly 
organizing  a  system  of  continuous  secretion, 
which,  effectively  done,  would  naturally  pro- 
duce Graves's  disease.  The  fact  of  temporary 
exhaustion  is,  I  think,  well  illustrated  by  Sir 
Almroth  Wright's  researches  on  the  calcium 
content  of  blood  in  relation  to  coagulability. 
He  found  that  calcium  salts  given  for  a  few 
days  increase  the  calcium  coefficient  and  raise 
the  coagulability  of  the  blood.  But  if  the 
dosage  be  continued  the  coagulability  actually 
falls  below  normal.  The  most  probable  ex- 
planation of  these  phenomena  would  appear  to  be 
that  the  first  doses  of  calcium  stimulate  thyroid 
activity,  by  which  they  are  duly  absorbed  and 
received  into  the  blood-stream.  After  a  few 
days,  however,  the  thyroid  gland,  owing  to 
exhaustion  or  self-protective  and  inhibitory 
impulses,  refuses  to  maintain  work  at  this  high 
level  and  is  now  unable  even  to  absorb  so 
much  calcium  as  formerly  from  the  food  supply. 
Assuming  excretion  to  continue  at  a  uniform 
rate  throughout,  a  shortage  would  thus  soon 
occur,  and  this  would  obviously  happen  still 


GOITRE  63 

sooner   if  excretion  occurred  at  a  more  rapid 
rate  during  the  time  of  increased  calcium  intake. 
I  had  a  patient  in  whom  a  few  doses  of  calcium 
lactate    so    exhausted    an    already    inefficient 
thyroid  as  actually  to  induce  what  I  believe  to 
have    been    a  transient   phase  of   myxcedema. 
The    point    is  important,    so   I   will   quote  the 
case    more    fully.     Mrs.    P.,    aged    37,   had   a 
goitre  dating  from  puberty.      It  had  increased 
in  size  with  successive  pregnancies,  and  became 
still  worse  after  nursing  her  mother  during  a 
year's  illness.     She   then   went  to  a  hospital, 
where  the  right  lobe  of  the  goitre  was  partially 
removed,  but   it  appears  that  some  difficulty 
arose,  as  the  operation  took  four  hours  (this  is 
the   patient's    story),  and    was  not  completed. 
She   stated  that  on   the  whole  she  has   been 
worse  since.     She  had  suffered  much  pain  on 
the    right   side   of    the   neck   since,    and    had 
paralysis  of  the  right  vocal  cord  which  made 
talking  an  effort.     I  mention  this    because   it 
probably  contributed    towards  depressing    her 
general    health.      She    still   had   considerable 
enlargement  of  the  middle  and  left  lobes  of  the 
goitre,  causing  dyspnoea,  by  tracheal  pressure. 
Her  neck  measured    15!  in.   in  circumference 
over    the    swelling,  her    pulse    was    92    and 
her    respirations    27.      Bowels    regular.      No 
excessive     thirst.      Menstruation     scanty     as 
always,  troublesome  cough,  great  lassitude  and 


64  THYROID    THERAPY 

unfitness  for  exertion.  She  was  corpulent  and 
slept  badly.  Now  in  this  case  I  confess  I  made 
a  mistake.  At  first  I  thought  that  thyroid 
secretion  was  probably  in  excess  rather  than 
deficient.  The  evidence  in  favour  of  adequate 
secretion  was  the  size  of  the  gland,  regularity 
of  bowels,  the  fact  that  she  was  a  mother^ 
absence  of  menorrhagia,  scanty  loss  of  blood  at 
confinements  (indicating  adequate  clotting 
power  of  the  blood),  absence  of  thirst,  and  the 
somewhat  rapid  pulse.  The  pulse  alone  would 
suggest  a  leaning  towards  Graves's  disease,  but 
actually  it  was  doubtless  due  to  dyspnoea 
caused  by  pressure  on  the  trachea. 

Acting  then  on  the  supposition  that  my 
patient  leaned  towards  Graves's  disease,  I  first 
gave  her  arsenic  and  belladonna.  She  did  not 
improve  on  this,  so  I  thought  I  would  see  if 
some  of  this  supposed  excess  of  secretion  could 
not  be  neutralized  by  calcium.  Accordingly  the 
belladonna  and  arsenic  mixture  was  repeated 
and  calcium  lactate  given  in  cachets  of  10  gr. 
three  times  a  day.  She  took  four  doses  and 
next  morning  on  waking  found  her  face  and 
eyelids  very  swollen,  and  not  only  her  face 
but  all  her  skin  "  felt  very  stiff  and  puffed. " 
She  did  not  take  any  more  of  the  calcium 
lactate  and  the  swelling  improved  the  next 
day,  but  she  did  not  altogether  lose  the  sensa- 
tion of  stiffness  in  the  skin  for  another  two  days. 


GOITRE  65 

There  was  no  smarting  or  irritation,  which 
negatives  the  explanation  of  urticaria.  Equally 
certainly  it  was  not  due  to  the  belladonna  or 
arsenic,  inasmuch  as  these  were  continued, 
and  had  also  been  taken  for  some  days  pre- 
viously, without  any  such  result.  Unfortu- 
nately, I  did  not  see  her  till  the  condition  had 
practically  subsided,  and  the  explanation  of 
myxcedema  did  not  occur  to  me  till  several 
days  afterwards.  Then,  however,  I  changed 
my  tactics  and  gave  her  thyroid.  The  benefit 
was  immediate  and  remarkable.  There  was  a 
very  obvious  diminution  in  the  growth,  though 
the  actual  circumference  only  diminished  f  in. 
during  the  six  weeks  she  was  under  observation. 
It  must  be  remembered,  however,  that  the 
enlarged  thyroid  often  spreads  out  to  a  con- 
siderable extent  superficially,  so  that  a  single 
circumferential  measurement  of  the  neck  does 
not  adequately  show  alteration  in  size.  Also 
the  |  in.  diminution  on  one  side  would  repre- 
sent f  in.  difference  had  both  lobes  been 
present.  Anyway,  the  patient  felt  very  much 
better  than  she  had  done « for  years.  She  lost 
weight,  and  felt  so  well  that  she  again  left  off 
her  medicine,  and  only  came  back  after  a  fort- 
night's abstinence  from  it  to  say  how  much 
better  she  felt,  and  to  point  to  her  decreasing 
size.  Actually  she  was  only  4  Ib.  lighter 
than  she  had  been  six  weeks  previously,  but 
5 


66  THYROID    THERAPY 

the  subjective  sensation  of  well-being  was  very 
marked.  If  then  calcium  neutralizes  thyroid 
secretion,  it  ought  to  be  a  useful  remedy  in 
Graves's  disease.  I  think  possibly  it  may  be 
of  some  value,  but  there  are  obvious  objections 
to  its  use.  We  have  seen  that  it  stimulates 
thyroid  activity.  This  would  be  most  objection- 
able in  Graves's  disease,  and  therefore  the  use 
of  calcium  would  be  limited  to  very  severe 
phases  in  which  one  might  fairly  assume  the 
thyroid  was  already  doing  its  worst.  I  have 
used  it  under  such  circumstances  and  benefit 
has  followed,  but  it  is  impossible  to  say  without 
further  experience  whether  it  was  due  to  the 
calcium  or  merely  coincidence. 

The  hard-water  districts  of  Kent,  Surrey, 
Wiltshire  and  the  Thames  Valley,  where  ordi- 
nary goitre  is  prevalent,  have  produced  a  re- 
latively large  proportion  of  cases  of  the 
exophthalmic  form  (Ord  and  Mackenzie).  It  is, 
therefore,  perhaps  hardly  rational  to  expect 
calcium  to  undo  the  mischief  that  calcium  has 
done.  On  several  occasions  I  administered 
calcium  lactophosphate  to  a  patient  suffering 
from  Graves's  disease  in  a  comparatively  mild 
form,  and  it  invariably  made  her  worse,  pre- 
sumably because  her  thyroid  was  still  capable 
of  further  stimulation.  Later  I  tried  the  effect 
of  limewater,  i  oz.  three  or  four  times  a 
day.  This  did  not  produce  any  immediate 


GOITRE  67 

result  that  I  could  detect,  but  later  I  came  to 
the  conclusion  that  it  did  harm  rather  than 
good.  The  pulse-rate  was  a  little  quicker  and 
the  blood-pressure  undoubtedly  considerably 
higher.  This  fact  alone  is  a  good  reason  for 
not  giving  calcium,  unless  it  can  be  shown  that 
the  gain  is  greater  than  the  loss.  If  the  blood- 
pressure  be  raised  and  the  pulse-rate  do  not 
decrease  in  frequency,  the  heart  is  obviously 
burdened  with  increased  work,  a  result  distinctly 
to  be  avoided  in  Graves's  disease.  Moreover, 
the  patient  complained  of  an  increased  sensa- 
tion of  hissing  in  the  ears  with  each  heart-beat, 
which  one  would  think  was  probably  due  to  the 
blood  being  forced  through  the  carotids  at  this 
increased  pressure.  If  calcium  is  to  be  given 
in  Graves's  disease  it  would  appear  that  the 
best  mode  of  administration  would  be  occasional 
large  doses  for  not  more  than  one  or  two  days 
in  succession,  repeating  the  dosage  after  a 
week's  interval,  if  indicated. 

Thus  far,  we  have  considered  calcium  chiefly 
from  the  point  of  view  that  in  excess  it  does 
harm,  and  probably  in  all  cases  of  simple  goitre 
it  would  be  well  to  eliminate  calcium  as  far  as 
possible  from  the  dietary,  and  to  avoid  it 
altogether  medicinally.  But  there  remains  a 
large  group  of  cases  (non-goitrous)  in  which  cal- 
cium is  useful,  especially  if  given  with  thyroid. 
This  includes  many  of  the  cases  of  thyroid 


68  THYROID    THERAPY 

insufficiency,  where  stimulation  is  distinctly 
useful.  But  even  in  these  cases  a  little  dis- 
cretion is  necessary.  If  the  gland  be  fatigued 
as  the  result  of  overwork,  it  is  obviously  better 
to  rest  it,  rather  than  exhaust  its  remaining 
activity  with  a  drug  like  calcium.  Therefore, 
in  many  cases,  it  will  be  well  to  commence 
treatment  with  thyroid  alone,  or  possibly,  com- 
bined with  small  doses  of  some  preparation  of 
iodine  (syrupus  ferri  iodidi  in  five-minim  doses 
answers  admirably),  and  when  the  gland  has 
had  a  few  weeks  of  such  assistance,  a  little 
calcium  will  be  beneficial.  I  find  the  syrupus 
calcii  lactophos.  a  most  useful  preparation  in 
such  cases,  and  am  inclined  to  think  the  phos- 
phorus element  is  also  beneficial  in  stimulating 
the  thyroid.  It  has  given  me  good  results  in 
thyroid  inadequacy,  and  seemed  to  be  less 
tolerated  in  Graves's  disease  than  other  pre- 
parations, but  there  may  have  been  some 
other  factor  at  work.  Calcium  is  obviously 
called  for  in  conjunction  with  thyroid,  in  all 
those  diseases  in  which  there  is  apparently  a 
deficiency  of  calcium  in  the  blood  or  tissues. 
This  probably  includes  all  haemorrhagic  con- 
ditions, in  which  we  must  not  forget  to  include 
a  special  liability  to  bruising  from  trifling  in- 
juries, various  forms  of  purpura  and  also  chil- 
blains. The  latter  are  quickly  benefited  by 
calcium  salts  alone  in  most  persons,  but  prob- 
ably the  calcium  ingested  with  the  food  would 


GOITRE  69 

be  sufficient  if  thyroid  activity  were  up  to  the 
mark.  Many  forms  of  urticaria  are  benefited 
by  calcium,  and  thyroid  has  also  proved  of 
very  great  assistance,  often  proving  effective 
without  any  calcium  other  than  that  in  the 
normal  food  supply. 

At  the  same  time  it  must  be  noted  that 
urticaria  sometimes  appears  to  be  the  result  of 
thyroid  excess,  and  1  have  seen  it  produced  by 
continuous  or  large  doses  of  thyroid  substance. 
This  anomaly  requires  further  elucidation,  but 
it  almost  looks  as  though  calcium  metabolism 
may,  under  such  circumstances,  proceed  so 
rapidly  that  excretion  exceeds  absorption,  and 
so  a  deficiency  occurs.  This  supposition  would 
also  explain  the  occasional  presence  of  chil- 
blains in  Graves's  disease. 

It  has  only  fallen  to  my  lot  to  treat  two  cases 
of  giant  urticaria,  a  condition  which  some  would 
term  angioneuritic  oedema.  Itching,  so  far  as 
I  recollect,  was  not  a  prominent  symptom  in  the 
first  case,  but  it  certainly  was  intense  in  the 
second.  Otherwise  both  cases  were  very 
similar,  large  patches  appearing  on  any  part  of 
the  body,  including  the  lips,  eyes  and  face,  with 
the  result  that  the  aspect  of  the  patient  was 
altered  beyond  recognition.  The  first  patient 
also  had  the  mucous  membrane  of  her  mouth 
and  throat  affected,  causing  such  urgent 
dyspnoea  as  to  make  one  wonder  whether 
tracheotomy  would  be  required.  The  affection 


7O  THYROID    THERAPY 

in  any  particular  place  did  not  last  more  than 
about  twenty-four  hours  in  this  patient,  but  the 
liability  to  it  did  not  show  any  very  rapid 
improvement  under  the  continued  administra- 
tion of  calcium  lactate,  though  ultimately  the 
girl  got  well.  My  second  case  was  a  girl  of 
about  20,  and  from  the  first  I  administered 
thyroid  with  calcium  lactate.  She  improved 
much  more  rapidly  than  the  other,  her  urticarial 
patches  only  lasting  a  few  hours,  and  ceasing 
to  appear  at  all  after  about  three  weeks'  treat- 
ment. Previously  she  had  suffered  inter- 
mittently, but  frequently,  for  about  two  months, 
and  she  showed  other  signs  of  thyroid  in- 
adequacy, which  improved  concurrently  under 
treatment.  There  has  been  no  recurrence  for 
over  six  months  at  the  time  of  writing. 

There  are,  of  course,  many  agents  which  will 
produce  urticaria,  and  it  is  difficult  to  suppose 
that  the  thyroid  and  calcium  supply  are  always 
affected.  Some  suffer  within  a  very  short  space 
of  time  after  eating  strawberries,  and  others 
after  eggs,  even  the  small  amount  of  egg  in  a 
single  piece  of  cake  being  ample  to  produce 
an  attack.  It  is,  nevertheless,  a  tempting  sup- 
position that  different  individuals  manufacture 
different  toxins  and  that  the  thyroid,  if  efficient, 
ought  to  be  able  to  deal  with  any  toxin  unless 
in  overwhelming  doses.  The  condition  of  each 
individual  thyroid  doubtless  varies  frequently, 
according  to  work  performed,  and  so  may  be 


GOITRE  71 

unable  at  one  time  to  deal  with  a  toxin  that 
would  be  efficiently  neutralized  at  another.  I 
have  many  times  been  stung  by  bees,  but  only 
on  two  occasions  did  this  produce  urticaria. 
It  does  not  seem  highly  probable  that  the 
formic  acid  injected  by  the  bee  varies  very 
much  in  quality,  so  the  explanation  must  be 
looked  for  in  my  own  condition,  though  I  doubt 
whether  I  had  much  more  than  heard  of  the 
thyroid  gland  at  the  time.  On  the  first  of 
these  occasions,  I  had  five  or  six  stings  on  my 
hands,  owing  to  my  foolishness  in  handling  the 
bees  with  woollen  gloves  on.  The  bees  get 
their  legs  entangled  in  the  glove,  and  vent  their 
wrath  immediately.  Within  half  an  hour  I 
had  an  intense  urticaria  over  my  whole  body 
from  feet  to  face,  accompanied  by  intense  head- 
ache and  intolerable  itching,  which  lasted  about 
two  hours.  On  the  second  occasion,  after  one 
sting  on  a  finger  of  the  right  hand,  the  urticaria, 
which  was  much  admired  by  a  medical  friend, 
was  limited  to  the  right  arm  and  fore-arm.  As 
I  have  said,  stings  on  other  occasions  never 
affected  me  except  locally,  so  the  urticaria 
might  have  resulted  during  a  period  of  lessened 
thyroid  activity  or  calcium  deficiency.  At  any 
rate,  there  would  be  no  harm  in  giving  calcium 
and  thyroid  treatment  a  trial,  in  most  cases  of 
urticaria,  not  forgetting  the  elimination  of  any 
offending  toxin,  where  there  is  any  evidence  of 
such  a  factor  being  present. 


CHAPTER    VI. 
Goitre — Iodine  and   the  Thyroid  Gland. 

ONE  cannot  always  tell  at  the  first  glance 
whether  the  secretion  from  an  enlarged  thyroid 
is  adequate  for  the  needs  of  the  body  or  ex- 
cessive. The  fact  of  enlargement  points  to  a 
previous  demand  for  secretion,  and  an  at- 
tempted response  on  the  part  of  the  organism. 
The  response  may  be  insufficient,  adequate  or 
excessive,  and  the  conditions  will  naturally 
vary,  being  further  influenced  by  possible 
changes  in  the  requirements  of  the  organism. 
But  speaking  in  general  terms,  the  patient  with 
an  enlarged  thyroid  probably  has  more  secre- 
tion than  one  without.  Many  patients  with 
enlarged  thyroids  are  practically  free  from  the 
stigmata  of  insufficiency,  though  signs  and 
symptoms  of  previous  insufficiency  can  often, 
indeed  usually,  be  found.  And  in  not  a  few 
cases  secretion  will  apparently  be  slightly  ex- 
cessive. This  is  merely  the  result  of  a  natural 
sequence  of  events.  There  is  a  period  of 
thyroid  exhaustion  followed  by  compensatory 
enlargement  and  increased  secretion.  If  the 
secretion  become  excessive,  a  reflex  diminution 


GOITRE  73 

of  the  gland  is  likely  to  occur,  and  the  goitre 
get  well.  This  sequence  is  constantly  seen  in 
the  goitres  of  puberty,  many  of  which  get  well 
spontaneously,  the  cure  being  attributed,  in 
many  cases,  to  any  cause  but  the  right  one.  But 
cure  does  not  always  follow.  Some  pathological 
factor  steps  in  and  interferes  with  the  natural 
sequence.  Here  is  our  opportunity  for  investi- 
gation. The  case  must  be  gone  into  thoroughly, 
and  by  careful  weighing  of  the  various  details 
there  is  reasonable  chance  of  arriving  at  a 
satisfactory  conclusion.  Elimination  of  un- 
favourable influences  will  materially  improve 
our  success  in  treatment.  Unfortunately,  the 
difficulty  is  to  know  what  are  the  unfavour- 
able influences.  The  possibility  of  pulmonary 
tubercle  must  always  be  remembered,  and  if 
present  this  must  have  the  prior  claim  to  treat- 
ment. Constipation  must  also  be  reckoned  as 
one  of  the  unfavourable  influences,  and  I  have 
noticed  an  immediate  and  marked  diminution  in 
the  size  of  a  goitre  produced  by  attention  to  this 
simple  point.  I  had  been  administering  thyroid 
to  this  patient  for  a  month  without  success,  and 
purposely  did  not  give  aperients,  because  I 
hoped  to  witness  the  beneficial  effect  of  thyroid 
in  this  direction.  It  became  evident,  however, 
that  purgation  was  a  necessity,  and  the  im- 
mediate result  (within  four  days)  was  a  diminu- 
tion of  over  an  inch  in  circumference  of  the 


74  THYROID    THERAPY 

goitre,  with  marked  softening  and  shrinking  of 
the  growth.  I  have  already  remarked  that  a 
single  circumferential  measurement  of  a  goitre 
is  a  fallacious  method  of  estimation.  The 
reason  is,  that  in  many  of  the  largest  goitres 
the  greatest  measurement  is  a  little  below  the 
cricoid  cartilage.  One  naturally  measures  the 
greatest  circumference,  which  is  usually  obvious. 
When  the  goitre  begins  to  diminish  there  is  a 
vertical  shrinkage,  and  often  a  very  obvious 
diminution  in  the  upper  poles  of  the  gland. 
The  maximum  girth  will  now  be  found  rather 
lower  down  than  previously,  and  a  measurement 
taken  here  obviously  does  not  give  a  correct 
impression  of  the  difference  in  the  size  of  the 
goitre,  as  the  neck  itself  (considered  apart  from 
the  goitre)  has  an  increasing  circumference 
towards  the  lower  part.  The  circumference 
may  also  vary  with  the  position  of  the  neck, 
to  the  extent  of  over  half  an  inch.  Some 
patients  are  able  to  get  the  sterno-mastoid 
muscles  forward,  over  the  lateral  margins  of 
the  goitre  and  so  compress  it,  more  or  less  like 
a  sponge.  This  diminishes  the  appearance  of 
the  goitre  even  more  than  it  does  the  actual 
measurement,  but  naturally  applies  especially 
to  the  softer  varieties.  Sometimes  variations 
in  size  are  transitory  and  of  purely  vascular 
origin,  and  I  have  observed  a  goitre  enlarge 
during  palpation.  This  patient  said  the  swell- 


GOITRE  75 

ing  always  got  larger  when  she  was  excited 
or  flurried.  Enlargement  commonly  occurs  at 
each  menstrual  period,  which  argues  that  some 
internal  secretion  of  sexual  origin  has  an 
antagonistic  and  therefore  stimulating  or  ex- 
hausting action  on  thyroid  secretion. 

Goitres  also  occur  at  the  menopause,  and 
thyroid  gland  has  been  administered  with  some 
success  in  the  "flushings"  so  prone  to  occur  at 
this  time  of  life.  The  rationale  is  not  very 
clear.  The  menopause  is  probably  a  period 
of  paroxysmal  ovarian  activity.  It  has  always 
appeared  to  me  that  "  flushings "  are  due 
to  paroxysmal  thyroid  activity.  The  one  may 
depend  on  the  other,  or  both  may  be  merely, 
so  to  speak,  the  dying  convulsions  of  glands 
which  are  doomed  to  relinquish  their  most 
important  functions. 

Undoubtedly  some  cases  are  benefited  by 
administration  of  thyroid,  and  others,  of 
ovarian  substance,  but  I  have  not  yet  learned  to 
discriminate  between  these  two.  "  Flushings  " 
may  occur  after  double  ovariotomy,  and  there- 
fore may  well  depend  on  thyroid  activity  inde- 
pendently of  ovarian  stimulation  or  antagonism. 
They  may  of  course  be  due  to  loss  of  ovarian 
antagonism — a  spasmodic  overflow  of  thyroid 
secretion  not  neutralized  by  secretion  of  the 
ovaries,  on  account  of  waning  function  in  the 
latter.  On  the  other  hand,  I  found  that  men- 


76  THYROID    THERAPY 

struation  was  induced,  after  periods  of  amenor- 
rhcea  lasting  nine  and  ten  months,  in  a  patient 
who  had  been  subjected  to  double  ovariotomy 
a  little  over  two  years  previously.  This  patient 
had  suffered  from  life-long  constipation,  and 
showed  other  signs  of  thyroid  deficiency.  Thy- 
roid medication  was  decidedly  beneficial,  but  in 
about  seven  weeks  menstruation  occurred  and 
was  repeated  four  times  at  intervals  of  about  a 
month  during  the  time  the  thyroid  was  being 
taken.  This  is  evidence  that  the  thyroid 
influences  uterine  activity  apart  from  ovarian 
secretion,  and  therefore  it  is  possible  that  the 
converse  is  true  also. 

•  The  case  is,  however,  open  to  a  different 
interpretation,  and  may  be  merely  another 
illustration  of  the  necessity  of  thyroid  for 
calcium  metabolism.  Recent  research  has 
shown  that  menstruation  itself  is  dependent 
on  calcium  metabolism,  that  calcium  is  in  some 
cases  a  remedy  for  amenorrhcea,  and  is  actually 
excreted  during  menstruation.  The  natural 
tendency  is  for  the  calcium  co- efficient  to  rise 
before  menstruation  and  fall  after,  and  irregu- 
larities in  this  process  may  be  responsible  for 
many  of  the  ills  to  which  the  female  flesh  is  heir. 
It  is  an  interesting  fact  that  the  headache  from 
which  so  many  women  suffer,  especially  after 
the  period  is  over,  may  be  benefited,  or  elimi- 
nated, by  the  administration  of  calcium.  In 


GOITRE  77 

the  case  under  consideration,  it  is  possible  that 
administration  of  thyroid  merely  caused  in- 
creased assimilation  of  calcium  from  the  food 
supply,  and  so,  indirectly,  induced  menstruation. 
The  activity  or  otherwise  of  an  enlarged 
thyroid  is  also  very  important  from  the  surgical 
point  of  view.  When  one  half,  or  even  the 
middle  lobe  only,  of  a  parenchymatous  goitre 
is  removed  surgically,  it  is  usual  for  the 
remainder  of  the  growth  to  disappear  rapidly 
and  spontaneously.  One  of  the  great  dangers 
of  the  operation  is  death  from  acute  thyroidism. 
So  much  thyroid  secretion  is  turned  loose  into 
the  system  by  the  necessary  manipulations  and 
by  leakage,  not  only  during,  but  after  the 
operation,  that  the  patient  commonly  shows 
signs  of  thyroid  intoxication,  and  a  good  many 
deaths  have  occurred.  But  is  not  the  big 
dose  of  thyroid  secretion  thus  absorbed  the 
immediate  cause  of  the  atrophy  which  follows 
in  the  favourable  cases  ?  The  nervous  system 
flooded  with  thyroid  secretion  sends  powerful 
inhibitory  messages  to  the  gland,  which  accord- 
ingly atrophies  to  a  reasonable  size.  But  I 
have  already  quoted  one  case,  in  which  part  of 
the  gland  had  been  removed,  and  atrophy  of 
the  remainder  did  not  occur.  And  in  this 
case  it  was  shown  by  subsequent  events  that 
the  thyroid  gland  was  peculiarly  impotent. 
Hence,  the  patient's  system  did  not  get  flooded 


78  THYROID    THERAPY 

with  secretion  at  the  time  of  the  operation, 
and  the  favourable  termination  did  not  result, 
though  an  extraneous  supply  of  thyroid  imme- 
diately proved  beneficial. 

Cases  have  been  recorded  to  show  that 
removal  of  the  middle  lobe  only  (a  compara- 
tively simple  and  far  less  risky  operation)  is 
sufficient  to  cause  atrophy  of  the  rest  of  the 
gland.  This  result  cannot  be  a  question  of 
blood  supply  on  anatomical  grounds,  and  cer- 
tainly favours  the  explanation  already  given. 
But  what  we  usually  have  to  fear  after  an  ex- 
tensive operation  is  thyroid  toxaemia.  Recently 
I  assisted  at  the  removal  of  one  half  of  a  very 
large  thyroid  which  was  obviously  secreting 
too  much  for  the  welfare  of  the  patient.  We 
feared  the  case  might  drift  on  into  well-marked 
Graves's  disease.  Immediately  prior  to  the 
operation  the  anaesthetist  had  administered  a 
hypodermic  injection  of  strychnine  and  atropine, 
which  I  believe  proved  highly  beneficial.  The 
patient  was  remarkably  free  from  thyroidism 
after  the  operation,  and  I  suggest  that  the 
atropine  was  responsible,  inhibiting  secretion 
during  the  operation,  and  for  some  hours  after, 
and  thus  reducing  the  dangers  of  toxaemia. 
Nevertheless,  atrophy  of  the  remaining  lobes 
occurred  within  a  few  weeks,  so  the  dose  of 
thyroid  secretion  administered  by  surgical  in- 
terference was  still  adequate,  though  not 


GOITRE  79 

dangerously  excessive.  Some  have  suggested 
that  goitres  are  of  an  inflammatory  nature. 
This  is  possible,  some  being  distinctly  tender, 
but  the  outward  and  visible  signs  of  inflamma- 
tion are  often  conspicuous  by  their  absence. 
It  may  be  argued  that  the  secretion  from  an 
enlarged  thyroid  is  ineffective,  because  the  per- 
centage of  iodine  in  the  colloid  of  such  a  gland 
is  usually  found  to  be  below  the  normal.  This 
may  be  a  correct  conclusion,  but  is  not  neces- 
sarily so.  By  enlargement,  the  amount  of 
available  secretion  is  increased,  and  if  the 
actual  amount  of  iodine  remained  the  same,  or 
even  slightly  increased,  the  percentage  would 
nevertheless  be  lower. 

But  a  deficit  of  iodine  may  obviously  result 
either  by  excessive  use,  or  shortage  of  supply. 
The  question  of  supply,  taken  all  round,  is  pro- 
bably not  a  very  variable  one,  and  is  at  least 
unlikely  to  account  for  a  goitre  in  one  member 
of  a  family,  whilst  the  others  who  feed  at  the 
same  table  escape.  It  would  be  a  useful  piece 
of  research  work  to  ascertain  what  substances 
commonly  eaten  contain  iodine,  andl  in  what 
proportions.  Sea-weed,  which  is  used  as  a 
commercial  source  of  supply  (or  at  any  rate 
was  so  used  before  the  American  saltpetre  was 
found  to  contain  iodine  and -to  be- more  profit- 
able to  work),  only  contains  '5  per  cent,  of 
iodine.  But  iodine  is  probably  present  in 


80  THYROID    THERAPY 

many  vegetables  and  fruits,  though  in  much 
smaller  quantities.  Also  in  fish,  seeing  that 
the  food  of  the  latter  is  derived  primarily  from 
the  sea- weed  which  is  eaten  by  various  molluscs 
and  animalculae,  which  in  turn  are  eaten  by  the 
fish.  But  a  shortage  of  iodine  affects  whole 
districts,  as  related  by  Dr.  A.  Rendle  Short 
in  the  Bristol  Medico-Ckirurgical  Journal  for 
June,  1910.  In  certain  North  American  dis- 
tricts remote  from  the  sea,  serious  loss  occurred 
from  the  number  of  cretin  lambs.  Many  of 
the  sheep  and  dogs  were  goitrous.  But  the 
introduction  of  an  iodiferous  salt,  in  place  of 
pure  rock  salt  which  had  previously  been  ad- 
ministered to  the  creatures,  proved  an  effective 
remedy.  But  shortage  of  iodine  is  much  more 
likely  to  occur  as  the  result  of  excessive  use, 
rather  than  deficient  supply.  The  causes  of 
such  excessive  use,  in  other  words,  the  causes 
of  excessive  output  of  thyro-iodine,  and  result- 
ing thyroid  exhaustion,  are  still  somewhat 
obscure.  We  have  already  made  mention  of 
the  influence  of  ovarian,  and  possibly  uterine 
activity  at  puberty,  in  childbearing,  and  at  the 
menopause.  Also  of  the  influence  of  lactation, 
and  of  various  diseases  which  induce  thyroid 
exhaustion.  Goitres  may  also  occur  in  the 
male  sex  at  puberty.  There  is  obviously  no 
reason  why  a  goitre  should  occur  as  the  result 
of  brief  temporary  thyroid  exhaustion.  But 


GOITRE  8 1 

several  months  of  pregnancy  are  sufficient  to 
produce  a  palpable  enlargement  of  the  gland, 
perhaps  hardly  deserving  the  opprobrium  of 
the  word  goitre.  Any  condition  which  makes 
a  sufficiently  prolonged  demand  on  thyroid 
activity  will  tend  to  produce  hypertrophy,  or 
goitre.  But  the  greater  the  natural  activity 
of  the  gland,  the  less  will  be  the  need  for 
hypertrophy.  Therefore  when  goitre  occurs, 
it  is  either  a  confession  of  inadequacy,  or  a 
protest  against  excessive  dissipation  of  thyroidal 
products.  This  dissipation  may  be  apparently 
brought  about  by  drinking  water  to  be  found 
in  certain  limestone  districts,  where,  as  a  result, 
goitre  is  prevalent.  I  explain  this  on  the 
simple  assumption  that  all  calcium  entering 
the  system  is  immediately,  as  it  were,  ushered 
in  to  the  thyroid  gland  department.  Thence, 
it  is  duly  distributed  to  all  the  calcium-requir- 
ing tissues  in  the  body,  any  surplus  being  only 
excreted  as  waste.  Precisely  how  this  distri- 
bution occurs  is  for  me  merely  conjecture.  But 
as  a  very  crude  suggestion  let  us  suppose  for  a 
moment  that  in  the  process  of  absorption,  all 
calcium  has  to  be  turned  temporarily  into 
calcium  iodide,  the  iodine  being  afterwards 
again  liberated  into  the  blood  stream,  and  so 
sent  back  to  the  thyroid  as  a  " returned  empty." 
One  can  hardly  suppose  the  process  to  be  so 
perfect  that  there  is  no  loss.  Some  of  the 
6 


82  THYROID    THERAPY 

"  empties "   are    never    returned    at    all.       But 
with  reservations,   the  more  calcium  ingested, 
the  greater  the  loss  of  iodine  from  the  thyroid 
gland.     The  ultimate  result,  however,  depends 
on  other  factors.      Not  all   the  people  in  the 
district    get   goitres.       So    those    who    escape 
presumably  are    possessed    of    more    capable 
thyroids  or  are  less  subjected  to  demands  in 
other  directions  for  thyroid  secretion,  or  pos- 
sibly in  virtue  of  idiosyncrasies  as  to  diet  get 
more  iodine  into  their  systems.     The  amount 
of  iodine    required    is    of    course    exceedingly 
small.     The  marvel  is,  that  an  element  present 
in  the  system  in  such  minute  quantities  should 
be  possessed  of  such   profound  potentialities. 
"  Behold,    how    great    a   matter   a   little   fire 
kindleth."     The  development  of  goitre,   how- 
ever, does  not  in  any  way  remedy  the  iodine 
deficiency  unless  an  enlarged  thyroid  contains 
more    iodine   than  a  small   one.     Dr.   Rendle 
Short   suggests    that  the   thyroid    enlarges    in 
order  "  to  catch  more  iodine  from  the  blood 
stream."     But  possibly  a  small  thyroid  could 
catch  all   the  iodine  normally   present,  and  it 
seems    more     probable    that    hypertrophy    is 
merely  the    result   of  increased  blood   supply 
induced   by    increased     secretion.       If    iodine 
material  is  wanted  in  the  body  there  occurs  a 
reflex  activity  of  the    thyroid   gland.     If  the 
resulting  secretion,  on  account  of  deficiency  in 


GOITRE  83 

iodine,  does  not  satisfy  the  needs  of  the  body 
the  demand  for  more  secretion  is  still  insistent 
and  increased  blood  supply  becomes  continu- 
ous, resulting  in  over-nutrition  and  hyper- 
trophy. When  once  hypertrophy  is  established 
it  takes  a  considerable  time  to  reduce  the 
thyroid  to  normal  dimensions.  And  though  in 
the  case  of  the  sheep  already  mentioned,  an 
adequate  supply  of  iodides  could  prevent  the 
occurrence  of  goitre,  the  cure  of  a  goitre  once 
established  is  a  different  matter.  Many  goitres 
are  never  cured  by  iodides  at  all.  Those  that 
are  generally  take  a  long  time.  This  may  be 
because  we  do  not  at  present  know  how  to 
present  the  iodine  in  a  form  ready  for  immed- 
iate use.  Iodide  of  potassium,  for  instance, 
is  quickly  eliminated  in  the  urine.  The  exact 
proportion  so  recoverable  I  do  not  know. 
Thyroid  gland  substance  or  thyro-iodine  itself 
would  naturally  give  the  best  results,  but  even 
they  hardly  come  up  to  expectations  in  rapidity 
of  action.  Even  supposing  that  we  provide 
the  patient  with  sufficient  thyro-iodine  to 
render  the  thyroid  potentially  idle,  the  question 
of  atrophy  is  not  fully  solved.  If  an  athlete 
lie  in  bed  his  muscles  will  certainly  waste  and 
get  flabby,  but  (apart  from  debilitating  condi- 
tions), the  muscles,  even  after  some  weeks, 
may  still  be  bigger  than  those  of  a  non-athletic 
man.  There  is  naturally  another  factor  to  be 


84  THYROID    THERAPY 

considered,  namely,  where  and  why  the  iodine 
wastage  occurs.  Goitre  is  but  a  symptom  and 
Science  must  find  and  treat  the  cause.  The 
cause  is  often,  if  not  always,  complex  and  may 
involve  factors  which  are  still  operative  as  well 
as  those  which  have  passed.  And  in  looking 
for  the  causes  one  must  remember  all  those 
which  we  have  seen  to  be  productive  of  thyroid 
deficiency,  inasmuch  as  goitre  is  a  product  of 
continued  thyroid  deficiency  in  special  in- 
dividuals under  special  conditions.  The  logi- 
cal sequence  of  these  conclusions  is  that  thyroid- 
ectomy  (though  possibly  necessary  in  some 
cases)  is  not  the  scientific  treatment  of  goitre. 
The  result  may  appear  to  be  perfectly  success- 
ful at  the  time,  as  indeed  it  did  in  the  case  of 
the  patient  last  quoted.  The  goitre,  as  men- 
tioned, entirely  disappeared,  and  she  felt  better 
than  for  years  previously.  But  six  months 
after  her  operation  she  again  noticed  some 
enlargement  of  the  remaining  lobe,  and  four 
months  later  still  there  was  a  very  obvious 
enlargement,  thus  proving  that  the  demand  of 
the  organism  for  thyroid  secretion  was  still 
insistent,  and  Nature  was  again  attempting  to 
supply  the  want  by  inducing  hypertrophy  of 
the  remaining  portion  of  the  gland.  We  there- 
fore yet  need  to  be  shown  a  more  excellent 
way,  for  thyroid  medication  does  not  always 
solve  the  problem. 


CHAPTER  VII. 
Iodine  and  Graves's  Disease. 

THE  victim  of  Graves's  disease  usually  de- 
velops a  goitre.  In  some  cases  the  order 
may  be  reversed,  and  the  victim  of  a  goitre 
may  develop  Graves's  disease,  but  not  in- 
frequently the  first  condition  is  one  of  hyper- 
activity  in  a  normal  sized  thyroid,  and  the 
goitre  develops  as  the  result  of  such  activity 
and  increases  in  size  as  the  disease  progresses. 
But  here  the  products  of  secretion  are  in 
excess  of  the  demands,  and  so  far  as  we  can 
see,  exert  only  a  baleful  influence.  Many  of 
the  symptoms  of  Graves's  disease,  as  pointed 
out  by  Rendle  Short,  are  similar  to  those 
occurring  in  iodoform  poisoning,  from  which  he 
argues  that  iodoform  poisoning  is  a  condition 
of  acute  thyroidism.  He  cites  the  authority 
of  Oswald,  Hunt  and  Seidell  that  iodides  and 
iodoform  increase  the  amount  of  iodine  in  the 
thyroid  colloid,  with  a  corresponding  increase 
in  its  physiological  activity.  But  one  must 
not  lose  sight  of  the  fact  that  in  iodoform 
poisoning  the  iodine  is  introduced  from  an 


86  THYROID    THERAPY 

extraneous  source  in  relatively  large  quantities, 
and  though  it  may  stimulate  thyroid  activity  to 
excess,  some  of  the  iodine  probably  enters  the 
system  regardless  of  the  thyroid,  or  filters 
through  it,  producing  results  the  same  as  those 
of  over-production.  To  look  at  the  matter  in 
a  slightly  different  light,  Graves's  disease  may 
be  considered  as  a  form  of  chronic  iodine 
poisoning,  though  we  cannot  suppose  that 
there  is  usually  any  continuous  or  excessive 
supply  of  iodine  from  extraneous  sources. 
Whence  could  it  come  ?  The  victims  of 
Graves's  disease  are  commonly  eating  the  same 
food  and  are  subject  to  the  same  influences  as 
other  members  of  the  household  who  do  not 
so  suffer.  If,  then,  the  symptoms  of  Graves's 
disease  are  not  due  to  excessive  intake  of 
iodine  into  the  system,  may  they  be  due  to  dimin- 
ished loss?  This  position  seems  hardly  more 
tenable  than  the  other.  At  the  same  time  we 
should  be  glad  to  know  how  iodine  is  normally 
excreted  from  the  system,  for  though  iodides 
medicinally  administered  may  be  quickly  de- 
tected both  in  saliva  and  urine,  I  have  never 
been  taught  that  iodine  is  a  normal  constituent 
of  urine.  Dr.  Rendle  Short  suggests  as  a 
remedy  for  Graves's  disease  an  iodine-free  diet. 
This  is  difficult  to  accomplish  because  the 
normal  intake  is  so  small  that  we  hardly  know 
whence  we  do  get  it.  But  the  potency  of 


IODINE    AND    GRAVES'S    DISEASE  87 

a  minute  quantity  of  iodine,  in  a  really  assimil- 
able form,  has  already  been  shown  in  the 
absence  of  rickets  from  babies  and  young 
animals  at  the  breast.  It  follows  that  an 
iodine-free  diet  involves  abstinence  from  milk 
and  cream,  and  probably  also  from  butter. 

When  looking  for  a  substitute  for  butter 
to  carry  out  this  plan,  a  patient  lighted  on  a 
preparation  called  walnut  butter,  which  was 
not  unpalatable  or  expensive.  But  I  was 
informed  that  analysis  showed  a  considerable 
quantity  of  iodine.  This  merely  illustrates  the 
difficulty  of  arriving  at  an  iodine-free  diet.  Dr. 
Rendle  Short  suggests  lean  meat  for  this 
purpose.  But  several  authorities  state  that 
raw  meat  is  an  excitant  of  thyroid  activity. 
(Dr.  Arnold  Lorand  quotes  three  authorities  in 
an  article  published  in  the  Lancet,  November 
9,  1907.)  I  do  not  know  to  what  extent 
cooked  meat  possesses  the  same  properties. 
Leonard  Williams  states  that  "  meat-food,  and 
alcoholic  drinks  in  excess,  are  depressors  of 
thyroid  activity."  The  only  way  to  reconcile 
these  two  apparently  contradictory  statements 
is  to  say  that  meat  stimulates,  and  therefore, 
in  excess,  exhausts  thyroid  activity.  Leonard 
Williams  writes  with  special  reference  to  cases 
of  thyroid  inadequacy,  and  these  would  naturally 
show  exhaustion  readily.  If,  then,  we  adopt 
the  meat  diet  for  Graves's  disease,  we  have  to 


88  THYROID    THERAPY 

run  the  risk  of  possible  thyroid  stimulation. 
Dr.  Chalmers  Watson  produced  goitre  in  fowls 
by  limiting  them  to  meat  diet.  Dr.  Rendle 
Short's  explanation  of  this,  is  that  goitre  was 
due  to  iodine  deprivation,  as  in  the  case  of 
the  North  American  lambs.  I  am  not  pre- 
pared to  decide  which  of  these  three  views  may 
be  the  correct  one,  but,  indirectly,  all  are 
possibly  true.  It  is  a  significant  fact  that 
thyroid  deficients  have  an  instinctive  dislike  of 
meat.  And  lean  meat  proved  useless  in  the 
prevention  of  rickets  when  given  to  the  lion 
cubs  at  the  "  Zoo."  If  it  stimulated  the  thyroids 
of  the  young  lions,  there  was  evidently  no 
response,  perhaps  owing  to  the  absence  of  a 
working  supply  of  iodine.  But  even  if  we 
succeed  in  evolving  an  iodine-free  diet,  we  do 
not  really  strike  at  the  root  of  the  trouble, 
inasmuch  as  Graves's  disease  is  only  exception- 
ally due  to  an  excessive  supply  of  iodine  (i.e., 
in  those  cases  induced  by  iodoform  poisoning). 
The  same  objection  applies  to  the  alternative 
of  finding  some  means  of  eliminating  all  the 
iodine  from  the  system,  by  means  of  the  water 
of  a  goitre  well.  Nevertheless,  if  we  could  by 
these  means  obtain  control  of  the  iodine  factor, 
we  might  hope  so  to  arrange  matters  that  the 
thyroid  might  be  induced  to  return  to  its 
former  state  of  responsibility  in  regulating  the 
metabolism  of  this  essential  element,  without 


IODINE    AND    GRAVES'S    DISEASE  89 

"  running  amok,"  as  it  does  in  Graves's  disease. 
But  I  do  not  think  the  cause  of  Graves's  disease 
is  to  be  found  in  a  simple  accumulation  of  iodine. 
I  humbly  offer  the  following  theory  of  its 
pathology.  I  suggest  that  the  thyroid  glands 
of  all  of  us  normally  contain  a  certain  amount 
of  iodine  stored  as  an  inert  compound,  a 
gradual  disintegration  taking  place,  according 
to  the  dictates  of  the  animal  economy.  This 
supposition  has  many  physiological  parallels  in 
fibrinogen,  mucinogen,  glycogen,  and  all  the 
other  <4  gens  "  or  substances  by  means  of  which 
a  material  is  stored  inert  until  required.  Now 
we  know  that  the  amount  actually  present, 
though  not  great,  is  fairly  constant  in  health  ; 
that  the  intake  is  necessarily  variable  and 
precarious,  and  the  normal  excretion  is  so  small 
that,  so  far,  we  are  hardly  able  to  do  more  than 
conjecture  about  it.  It  is  only  natural,  then, 
that  some  provision  should  be  made  for  the 
preservation  and  retention  in  the  body  of  such 
an  essential  material,  the  supply  of  which  is  so 
precarious.  In  short,  that  the  same  iodine  is 
used  over  and  over  again,  being  liberated  from 
the  thyroid  storehouse,  performing  its  functions, 
(one  of  which,  is  that  of  acting  as  a  lime- 
carrier),  and  returning  empty  to  the  thyroid, 
where  it  again  enters  into  suitable  combination 
and  is  again  stored  till  required.  Under  these 
conditions  it  seems  probable  that  Graves's 


90  THYROID    THERAPY 

disease  is  the  result  of  an  excessive  discharge 
of  the  reserve  iodine  into  the  system,  by  the 
chemical  disorganization  of  the  substance  which 
normally  holds  it  in  storage.  The  iodine  thus 
turned  loose  into  the  system  produces  the  well- 
known  group  of  symptoms  collectively  known 
as  Graves's  disease  (many  of  which,  as  we  have 
seen,  are  present  in  iodoform  poisoning) ;  and 
is  re-collected  by  the  normal  conservative 
system,  returned  to  the  thyroid  gland,  and 
again  discharged  before  it  is  required,  so  keep- 
ing up  the  condition  of  toxaemia.  Thus  a 
sudden  explosion  in  the  iodine  stores  of  the 
thyroid  gland  is  all  that  is  needed  to  flood  the 
system  with  iodine  and  start  Graves's  disease. 
This  is  probably  what  occurs  when  the  disease 
is  started  by  a  fright,  or  a  sudden  shock,  a 
mode  of  onset  which  suggests  that  the  explod- 
ing spark  may  be  some  product  of  nervous 
katabolism.  The  well-known  nervous  symptoms 
of  the  disease  further  suggest  that  perhaps 
such  a  product  is  being  continually  formed,  and 
exploding  the  iodine  storage  material  as  fast 
as  it  is  re-formed.  I  do  not  wish  to  lay  undue 
stress  on  this  suggestion  as  to  what  the 
exploding  agent  may  be.  For  we  do  not  know 
by  what  agency  iodine  is  normally  set  free 
from  the  thyroid  gland,  though  we  suppose 
that  it  is  governed  by  laws  of  chemistry, 
controlled  by  nervous  impulses.  A  sudden 


IODINE    AND    GRAVES  S    DISEASE  91 

shock  sends  impulses  helter-skelter  down  any 
of  the  nerves,  and  may  produce  various 
physiological  results — a  leap,  a  shout,  the 
secretion  of  tears,  vomiting,  or  the  passage  of 
urine.  Why  not  also  a  thyroid  explosion  ?  It 
is  not  so  easy  to  explain  why  the  condition 
should  become  continuous  in  the  case  of  the 
thyroid,  though  transitory  in  the  instances 
quoted.  But  permanent  disorder  of  the  brain 
may  follow  sudden  shock.  Why  not  long 
continued  or  permanent  disorder  of  the  thyroid 
innervation  ?  Again,  destruction  is  always 
more  rapid  than  construction,  and  it  may 
well  take  a  long  time  to  capture  and  firmly 
tie  up  this  iodine  which  has  got  loose  in 
the  system.  Possibly,  a  "  vicious  circle  "  has 
become  established. 

In  those  cases  where  Graves's  disease  be- 
comes grafted  on  to  an  ordinary  parenchy- 
matous  goitre,  perhaps  one  may  suppose  that 
the  gland,  in  response  to  the  needs  of  the 
organism,  has  acquired  a  habit  of  throwing  all 
available  iodine  into  the  circulation.  But 
when  the  iodine  is  no  longer  required  in 
quantity,  owing  to  alteration  of  the  conditions 
which  previously  demanded  it,  the  inhibitory 
mechanism  having  lain  idle  for  some  time  has 
got  rusty  and  will  not  work.  A  habit  has  been 
formed  which  is  hard  to  break.  Such  a  condi- 
tion is  comparable  to  the  repeated  discharge 


92  THYROID    THERAPY 

of  nervous  energy  in  epilepsy,  or  perhaps  to 
the  continued  transformation  of  glycogen  into 
sugar  in  diabetes. 

Next  let  us  consider  how  far  the  surgical 
treatment  of  Graves's  disease  bears  out  or 
contradicts  these  theories.  Briefly,  the  sur- 
gical treatment  consists  in  removal  of  part  of 
the  gland  or  in  cutting  off  part  of  the  blood 
supply.  It  is  evident  in  the  former  case  that 
the  removal  of  part  of  the  gland,  with  any 
iodine  material  it  may  contain,  will  do  good  if 
the  symptoms  of  Graves's  disease  are  due  to 
iodine  toxaemia.  Further,  part  of  the  iodine 
storehouse  is  removed,  and  therefore  however 
inefficiently  the  regulations  for  supply  and 
demand  may  be  working,  the  thyroid  is  now 
incapable  of  flooding  the  system  to  the  same 
extent  as  formerly.  Ligature  of  blood  vessels 
to  the  gland  produces  similar  results  by  a  pro- 
cess of  atrophy.  It  would,  therefore,  appear 
that  one  cannot  expect  surgical  treatment,  ipso 
facto,  to  cure  the  disease.  The  symptoms 
certainly  will  be  improved,  but  the  resulting 
condition  will  depend  on  how  far  an  equilibrium 
has  been  restored  between  supply  and  demand. 
If  the  remaining  portion  of  gland  be  still  suffi- 
cient to  contain  more  iodine  than  is  required 
by  the  system  at  any  given  moment,  and  owing 
to  faulty  innervation  the  whole  or  greater  part 
of  that  excessive  quantity  be  poured  into  the 


IODINE   AND    GRAVES  S    DISEASE  93 

system,  a  condition  of  Graves's  disease  will  still 
remain,  though  obviously  the  toxaemia  will  be 
less.  Cure  will  only  result  by  an  adjustment 
of  the  nervous  control,  failure  of  which  has 
given  rise  to  the  disease.  This  adjustment  is 
naturally  more  likely  to  be  brought  about  if  we 
can  improve  the  bodily  health.  So  it  is  still 
right  to  attack  the  various  symptoms  if  by  so 
doing  we  improve  the  general  condition, 
though  obviously  we  should  strive  to  turn  the 
stream  of  evil  as  near  the  source  as  possible. 
We  must  try  to  solve  the  various  problems 
which  appear  to  be  presented.  What  causes 
this  constant  explosion  of  the  iodine  material  ? 
What  is  the  normal  agent  which  sets  free 
thyro-iodine  from  the  gland  ?  Analogy  sug- 
gests that  it  is  some  ferment.  The  symptoms 
of  the  disease  and  its  common  mode  of  origin 
suggest  that  it  is  some  product  of  nervous 
katabolism.  But  possibly  the  thyroid  is  trying 
to  accomplish  some  good  purpose  in  this  ex- 
cessive secretion.  Perhaps  the  sufferer  from 
Graves's  disease  is  thus  saved  from  some  other 
condition  which  might  be  even  worse.  Ob- 
viously the  mere  attempt  to  neutralize  thyroid 
secretion,  or  to  exhaust  the  thyroid  gland,  is 
not  the  most  scientific  procedure.  Any 
attempt  to  neutralize  the  secretion,  if  success- 
ful, would  tend  to  stimulate  the  production  of 
more.  But  till  we  have  solved  these  problems, 


94  THYROID    THERAPY 

we  may  very  well  try  to  obtain  some  control 
over  the  iodine  supply  and  demand.  This 
involves  a  study  of  all  those  conditions  which 
have  any  bearing  on  thyroid  activity.  The 
plan  which  commends  itself  to  me,  is  to  put 
the  patient  on  a  diet  which  has  been  found  by 
experience  to  be  conducive  to  rickets,  which  I 
have  already  gone  into.  I  have  not  yet  com- 
pleted my  tests  of  this  treatment,  but  the 
immediate  results  in  two  cases  have  been  very 
encouraging.  It  is  unsafe  to  argue  from 
solitary  cases,  as  individual  idiosyncrasies  and 
coincidences,  depending  perhaps  on  other 
unobserved  factors,  may  lead  one  to  hopelessly 
wrong  conclusions.  I  do  not  wish  in  any  way 
to  discount  the  recognized  methods  of  treat- 
ment of  Graves's  disease  by  rest  in  bed,  open- 
air,  electricity,  the  application  of  ice  to  the 
neck  or  praecordium,  inunction  of  the  gland 
with  red  iodide  of  mercury,  the  administration 
of  thymus,  "rodagen"  and  other  "anti- thyroid" 
bodies,  nor  the  use  of  such  drugs  as  phosphate 
ofsoda,  arsenic,  belladonna,  digitalis,  and  so 
forth.  Those  who  study  the  matter  will  be 
able  to  form  their  own  conclusions,  and  it  is 
well  to  have  a  method  in  one's  madness. 
Successful  cases  have  been  published  from 
time  to  time  treated  by  widely  different 
methods.  One  of  the  difficulties  in  estimating 
results  is,  of  course,  the  tendency  to  a  spon- 


IODINE    AND    GRAVES  S    DISEASE  95 

taneous  cure,    after  a  variable  period,   in  most 
cases.      The  last  used  treatment  is  likely  to 
get  the  credit,  and  very  likely  be  published  if 
the  case  has   been   a  long    one,    inasmuch    as 
other  recognized  methods,    perhaps    in    skilful 
hands,   had    previously    failed.       It    is    a    trite 
saying  that  the  longer  the  list  of  remedies  for 
any  disease  the  more  futile  they  are  likely  to 
prove.     A  remedy  which  has  proved  useful  in 
the    hands    of    one    may    appear    valueless    to 
another.     Take  for    instance   digitalis.      I    be- 
lieve that  most  observers  are  agreed  that  it  is 
of  little  value  in  Graves's  disease.      If  it  does 
not  slow  the  pulse,  it  probably  does  raise  the 
blood  pressure,   which  is  theoretically   wrong. 
Yet    such    an   observer   as    Trousseau   was   a 
strong  advocate  for  digitalis.     Possibly  he  may 
have  been  the  possessor  of  a  potent  form  of 
digitalis,  which  appears  to  vary  greatly  accord- 
ing to  the  soil  and  climate.     Personally,  I  have 
given  up  using  non-standardized  preparations 
of  the  drug,  and  generally  rely  on  Nativelles' 
granules   of  crystallized  digitalin,  if  an  imme- 
diate   and   certain  result    is    necessary.       One 
patient  whose  case  has  already  been  discussed 
was  also  very  definite  in  her  reliance  on  these 
41  little    pills "    as    a    remedy    for    palpitation, 
though   she  did  not  know   what  they  were. 

I  cannot  help  thinking  that  the  administra- 
tion   of  thyroid    in  Graves's   disease  deserves 


96  THYROID    THERAPY 

more  consideration  than  is  now  commonly 
accorded  to  it.  In  the  early  days  of  thyroid 
knowledge  it  was  doubtless  frequently  given, 
and  probably  in  very  excessive  doses.  In 
most  cases,  it  not  all,  one  must  assume  that 
large  doses  would  be  badly  borne.  But  some 
successes  have  been  reported.  Are  these  all 
to  be  regarded  as  coincidences  ?  The  argu- 
ment against  thyroid  is  patent  to  everyone. 
When  the  gland  is  already  secreting  a  lot  too 
much,  why  give  more  ?  But  there  is  another 
equally  cogent  argument  on  the  other  side, 
though  not  quite  such  a  superficial  one.  May 
we  not  suppose  that  in  Graves's  disease  there 
is  some  other  primary  condition  at  fault,  a 
toxin  or  what  not,  which  the  thyroid  gland  is 
heroically  endeavouring  to  counteract.  But 
like  some  other  well-meant  endeavours,  it  does 
more  harm  than  good.  In  other  words  the 
remedy  is  worse  than  the  disease.  Now  if 
this  be  a  correct  view  of  Graves's  disease,  it  is 
obvious  that  a  small  dose  of  thyroid,  several 
times  a  day,  may  very  well  intercept  or  restrain 
this  insistent  demand  for  the  secretion  of  the 
patient's  own  gland.  By  continuance  of  such 
treatment,  one  might  hope  to  dull  the  nervous 
susceptibilities  of  the  gland  to  the  constant 
demands  made  upon  it,  and  by  degrees  to 
lessen  the  habit  of  hyper-activity.  The  addi- 
tion of  further  thyroid  might  even  accomplish 


IODINE    AND    GRAVES  S    DISEASE  97 

the  task  which  the  gland  is  attempting  to  per- 
form, thus  removing  the  source  of  the  evil. 
The  same  arguments  are  of  course  applicable 
to  large  doses  of  thyroid,  but  one  can  readily 
see  that  the  immediate  effect  would  be  to  in- 
crease the  evils  of  hypersecretion,  and  possibly 
the  patient  might  succumb.  Anyone  using 
large  doses  would  therefore  in  all  probability 
speedily  be  forced  to  desist.  This  line  of  treat- 
ment would  therefore  have  to  be  used  only  in 
the  earlier  cases,  and  they  would  need  to  be 
put  to  bed  for  the  purpose. 


98 


CHAPTER    VIII. 
Lymphatic  Glands  and  Graves's  Disease. 

IN  the  last  chapter  some  stress  was  laid  on 
the  possibility  of  Graves's  disease  being  the 
result  of  an  explosion  in  the  iodine  stores  of 
the  thyroid  gland,  and  consequent  poisoning 
of  the  system  with  iodine  in  the  highly  toxic 
combination,  in  which  it  is  normally  supplied 
to  the  tissues  by  the  thyroid  gland.  It  was 
suggested  that  the  explosion  may  occur  as  the 
result  of  a  fright,  or  of  prolonged  nervous 
stress.  A  " nervous"  condition  is  sometimes 
the  precursor  and  apparently  the  cause  of 
Graves's  disease.  On  the  other  hand,  Graves's 
disease  certainly  highly  increases  any  nervous 
symptoms  which  were  previously  existent,  and 
originates  others.  Here  is  possibly  the  vicious 
circle  which  makes  Graves's  disease  so  hard  to 
cure.  But  there  is  no  reason  why  the  disease 
should  not  be  started  in  other  ways.  I  have 
already  suggested  diabetes  as  a  parallel. 
Numerous  and  varied  are  the  causes  which 
appear  to  be  factors  in  the  production  of 
diabetes.  Yet  when  the  disease  is  established 
the  whole  group  of  symptoms  is  sufficiently 


LYMPHATIC  GLANDS  AND  GRAVES's  DISEASE     99 

characteristic  to  be  designated  by  a  definite 
name,  though  obviously  if  one  can  differentiate 
the  mode  of  origin,  a  definite  line  of  individual 
treatment  is  more  likely  to  be  successful  than 
the  usual  general  measures.  Similarly  in 
Graves's  disease  we  have  a  general  grouping 
of  symptoms  sufficient  to  mark  the  name  of 
the  ailment,  yet  varying  in  different  individuals 
to  a  considerable  extent,  and  possibly,  as  in 
diabetes,  there  are  various  modes  of  origin. 
Any  cause  which  evokes  thyroid  secretion 
may,  theoretically,  be  a  cause  of  Graves's 
disease.  The  question  is  practically  one  of 
supply  and  demand.  There  is  in  Graves's 
disease  a  curious  association  of  several  factors, 
a  manifestation  of  activity  in  other  glands. 
The  thymus  is  said  to  be  invariably  enlarged, 
and  usually  one  finds  enlarged  lymphatic 
glands  in  the  neck.  This  latter  symptom  is 
all  the  more  curious  because,  as  Leonard 
Williams  remarks  (and  I  have  often  been  able 
to  confirm  it),  children  who  are  thyroid  de- 
ficients, very  frequently  have  enlarged  cervical 
glands,  and  the  administration  of  thyroid  ex- 
tract causes  atrophy  of  these  compensatory 
hypertrophies.  Conversely,  however,  the  ad- 
ministration of  thyroid  substance  is  said  some- 
times to  cause  enlargement  of  the  glands  under 
the  angle  of  the  jaw,  which  hypertrophy  disap- 
pears when  the  remedy  is  left  off.  In  this  latter 


IOO  THYROID    THERAPY 

case,  however,  there  is  perhaps  the  question  of 
tubercle,  which  seems  to  thrive  on  thyroid 
medication.  The  glands  under  the  jaw,  and 
therefore  nearest  the  tonsils,  would  probably 
form  the  first  line  of  defence.  Probably  in  all 
of  us  these  glands  are  dealing  with  tubercle 
bacilli  pretty  frequently,  fortunately  with  suc- 
cess in  most  of  us,  and  it  is  possible  that 
thyroid  medication  assists  the  tubercle  bacilli 
to  the  extent  of  necessitating  glandular  en- 
largement, though  no  further  mischief  appears 
to  result.  The  same  explanation  would  of 
course  be  applicable  in  Graves's  disease,  the 
enlargement  spreading  to  most  of  the  cervical 
lymphatics  under  the  influence  of  prolonged 
thyroid  activity.  But  this  explanation  does 
not  seem  highly  probable  in  either  case.  If 
it  were  so,  we  should  almost  certainly  meet 
with  caseation  and  suppuration  in  such  tuber- 
culous glands  not  infrequently  in  cases  of 
Graves's  disease.  Yet  such  an  occurrence  must 
be  rare.  Therefore  we  must  look  for  some 
other  explanation  than  tubercle  to  account  for 
these  enlarged  cervical  glands.  It  is  probable 
that  the  morbid  condition  which  stimulates 
thyroidal  activity  is  so  urgent,  that  it  affects 
what  may  be  called  the  deputy- thyroid  organ- 
ization as  well.  The  age  for  gross  enlarge- 
ment of  tonsils  and  adenoids  is  now  passed, 
so  they  are  not  added  to  the  picture.  In 


LYMPHATIC  GLANDS  AND  GRAVES's  DISEASE    IOI 

lymphadenoma  hypertrophy  of  adenoid  tissue 
in  the  pharynx  as  well  as  other  parts  is  com- 
monly present.  In  this  disease  also  the  first 
glands  to  enlarge  are  commonly  these  same 
cervical  glands  which  we  have  just  been  dis- 
cussing. Further,  in  lymphadenoma  as  well 
as  Graves's  disease,  thymus  enlargement  is 
commonly  if  not  invariably  present.  Here  is 
a  remarkable  coincidence.  Now  Dr.  John 
Orr  has  published  a  case  of  lymphadenoma 
which  was  cured  by  the  administration  of 
thyroid  extract  after  other  means  had  failed. 
In  view  of  these  facts  it  is  impossible  not  to 
make  the  deduction  that  the  lymphatic  glands 
certainly,  and  probably  the  thymus  also,  may 
come  to  the  rescue  of  the  thyroid  gland  when 
the  secretory  capacity  of  the  latter  is  over- 
taxed, or  inefficient.  But  in  lymphadenoma 
thus  arising,  the  result  is  comparable  with  that 
in  the  old  fable  of  the  bear  who  was  keeping 
the  flies  away  from  his  sleeping  master's  face. 
One  fly  returned  again  and  again,  with  the 
accustomed  pertinacity  of  its  kind,  till  the 
bear  in  desperation  killed  it  with  a  blow  of  his 
paw,  as  it  rested  on  the  man's  cheek.  Thus 
the  lymphatic  glands  in  their  well-meant  en- 
deavours to  assist  the  thyroid  may  kill  the 
patient  with  the  disease  which  we  call  lympha- 
denoma. More  scientifically  expressed,  I  wish 
to  infer  that  lymphadenoma  is  the  result  of  a 


IO2  THYROID    THERAPY 

futile  attempt  on  the  part  of  the  lymphatic 
glands  to  resist  the  invasion  of  a  poison  (prob- 
ably microbic  in  origin)  which  an  efficient 
thyroid  would  never  have  allowed  to  pass  its 
portals.  Conversely  it  is  possible  that  Graves's 
disease  is  merely  the  result  of  a  well-meant 
endeavour  on  the  part  of  the  thyroid  to  do 
work  which  should  have  been  carried  out  by 
the  lymphatic  glands.  The  enlargement  of 
the  thymus  in  each  case  looks  as  though  that 
gland  were  capable  of  assisting  either  the 
thyroid  or  lymphatic  glands  when  these  struc- 
tures are  being  worked  to  their  full  capacity, 
On  the  other  haud,  some  have  thought  that  the 
thymus  is  in  some  way  antagonistic  to  the 
thyroid,  and  enlarges  in  Graves's  disease  in 
order  to  protect  the  body  from  the  mad  career 
of  the  thyroid  gland.  The  same  argument 
could  be  applied  to  the  case  of  thymus  en- 
largement in  lymphadenoma.  Thymus  has 
been  administered  in  Graves's  disease  with 
some  success,  as  a  supposed  antidote  to  thyroid 
secretion.  So  far  as  my  own  brief  experience 
goes,  the  action  appeared  to  be  beneficial  in 
some  slight  degree,  but  I  thought  it  was  re- 
sponsible for  a  rise  in  blood  pressure.  But 
granted  that  thymus  is  beneficial  in  Graves's 
disease,  it  does  not  follow  that  the  two  secre- 
tions are  antagonistic.  Thymus  is  certainly 
far  less  toxic  to  the  organism  than  thyroid, 


LYMPHATIC  GLANDS  AND  GRAVES's  DISEASE    10$ 

and  the  explanation  of  the  benefit  may  very 
well  be  that  the  administration  of  thymus  in 
Graves's  disease  does  some  of  the  work  which 
the  thyroid  is  so  viciously  engaged  upon,  and 
thereby  actually  lightens  the  labours  and  secre- 
tions of  the  latter,  with  a  corresponding  decrease 
of  thyroid  toxaemia.  There  is  no  doubt  that 
all  the  internal  secretions  of  the  body  are 
interdependent  and  complementary.  All  have 
their  allies  and  opponents,  and  naturally  each 
has  some  property  peculiar  to  itself,  as  well  as 
properties  which  can  in  time  of  need  be  sup- 
plied more  or  less  (generally  less)  successfully 
by  other  glands.  But  the  excessive  activity 
of  the  deputy  gland,  though  it  may  partially 
fulfil  the  foreign  function  which  it  is  attempting 
to  perform,  may  result  also  in  an  excessive 
production  of  its  own  peculiar  secretion,  and 
give  rise  to  the  disease  which  we  recognize  by 
such  activity. 

In  the  light  of  Dr.  John  Orr's  case  of 
lymphadenoma,  it  might  be  worth  while  to 
try  the  converse  effect,  namely,  lymphatic 
gland  feeding  in  Graves's  disease.  In  this  case 
it  would  presumably  be  some  internal  secretion 
of  the  lymphatic  gland  that  would  be  required, 
and  might  possibly  be  preserved  in  a  dried 
but  active  condition  in  the  prepared  gland. 
This  gland  feeding  has  been  tried  for  tuber- 
culosis, on  the  ground  that  sheep  are  very 


IO4  THYROID    THERAPY 

immune  to  the  tubercle  bacillus,  and  hence  it 
was  argued  that  the  bronchial  glands,  which 
would  form  the  first  or  second  line  of  defence 
in  case  of  pulmonary  infection  by  the  tubercle 
bacillus,  might  possess  some  special  antitoxic 
power.  One  observer  is  quoted  by  the  pur- 
veyors of  this  gland  preparation  as  saying, 
''The  remedy  must  be  used  with  caution  in 
Graves's  disease,"  as  he  had  seen  ill  effects 
produced.  Now  this  observation  is  at  any 
rate  evidence  that  the  dry  gland  has  active 
powers  akin  to  those  of  the  thyroid,  and  there- 
fore in  suitable  doses  it  should  be  beneficial, 
if  by  any  chance  Graves's  disease  is  merely 
the  result  of  a  well-meant  but  mistaken  attempt 
of  the  thyroid  gland  to  do  the  work  of  the 
lymphatic  glands.  It  would  also  obviously 
be  useful,  if  there  be  such  a  thing  as  lymphatic 
inadequacy.  In  a  recent  post-mortem  that  I 
was  privileged  to  see  on  a  case  of  Graves's 
disease  that  succumbed  a  few  days  after 
operation,  there  were  no  enlarged  lymphatic 
glands,  all  that  could  be  found  being  exceed- 
ingly small.  But  there  was  only  a  six  months' 
history  of  illness.  The  pancreas  weighed 
\\  oz.  instead  of  2^  oz.,  the  average  weight 
in  the  female,  which  is  an  interesting  comment 
on  the  fact  already  noticed,  that  thyroid  secre- 
tion exercises  an  inhibitory  influence  on  the 
pancreas.  I  have  observed  a  long-standing 


LYMPHATIC  GLANDS  AND  GRAVES  S  DISEASE    1 05 

case  of  Graves's  disease  in  which  the  tonsils 
were  practically  absent,  there  being  a  distinct 
hollow  in  the  situation  normally  occupied  by 
these  bodies.  This  case  was  probably  an 
example  of  the  effect  which  thyroid  secretion 
has  upon  the  tonsils.  If  excess  of  thyroid 
has  a  similar  inhibitory  effect  on  the  lymphatic 
glands,  which  is  not  unlikely,  we  are  furnished 
with  a  probable  reason  for  the  evil  influence 
of  thyroid  feeding  in  tuberculosis.  The  lym- 
phatic glands  are  absolutely  the  first  line  of 
defence  against  tubercle,  as  evidenced  by  their 
invariable  enlargement  in  this  disease.  Any 
inhibitory  influence  which  interferes  with  the 
defensive  power  of  the  glands  might  well 
encourage  tuberculosis,  though  the  thyroid 
probably  forms  the  second  line  of  defence  in 
this  disease. 


io6 


CHAPTER    IX. 
Thyroid  and  Eczema. 

ECZEMA  is  one  of  the  many  diseases  for 
which  thyroid  medication  has  been  advocated. 
In  view  of  this  fact,  the  history  of  the  following 
case  may  prove  interesting.  The  patient  was 
a  child  of  4  years  and  10  months.  He  had 
been  weaned  when  3  months  old,  and  eczema 
immediately  appeared  and  has  been  trouble- 
some ever  since,  sometimes  better  and  some- 
times worse.  After  weaning  he  was  fed  on 
condensed  milk,  milk  and  barley  water,  Mellin's 
Food,  Allenburys'  Food,  and  "  all  the  baby 
foods  "  in  turn  ;  but  at  six  months  was  so  bad 
that  he  had  to  be  put  in  a  nursing  home,  where 
he  stayed  six  weeks.  He  did  not  improve, 
however,  so  was  taken  into  the  country  and 
fed  on  humanized  milk,  which  seemed  to  suit 
him  and  he  promptly  got  better.  But  the 
respite  was  not  long,  and  attacks  have  been 
frequent  ever  since. 

His  eczema  affected  principally  the  genitals, 
perineum,  popliteal  spaces,  wrists  and  face, 
with  occasional  outbreaks  on  thighs  and  abdo- 


THYROID    AND    ECZEMA  1 07 

men.  His  scalp  was  not  affected.  Now  the 
curious  thing  about  this  boy  was  the  presence 
of  many  signs  of  abundant  thyroid  activity. 
His  height  was  3  ft.  6J  in.,  the  average  height 
of  a  child  a  year  older.  His  weight  3  St.,  that 
is  about  4^  Ib.  more  than  the  average  for  his 
age.  His  pulse  rate  varied  from  108  to  132, 
usually  about  1 20,  though  he  was  not  frightened 
or  unduly  excited,  for  we  soon  became  friends. 
His  teeth  were  perfect,  without  any  sign  of 
caries.  He  cut  his  permanent  incisors  (lower 
central)  at  the  age  of  4  years  and  10  months, 
and  the  gums  were  already  swollen  with  the 
unerupted  lower  "  sixes."  His  bowels  were 
open  twice  a  day.  He  was  sensitive  to  heat 
rather  than  cold,  and  preferred  few  bedclothes. 
He  was  very  subject  to  small  boils  of  the  acne 
type.  His  hair  was  thick,  though  rather  dry, 
and  mentally  as  well  as  physically  he  was 
much  ahead  of  his  years.  He  had  no  enlarge- 
ment of  the  tonsils  nor  symptoms  of  adenoids. 
He  was  constantly  saying  "  I'm  so  tired,"  or 
<4  I'm  so  thirsty."  I  have  already  commented 
on  thirst  as  a  symptom  frequently  present  in 
thyroid  inadequacy,  but  it  is  also  common  in 
Graves's  disease  as  is  also  the  sensation  of 
fatigue.  The  boy  was  made  much  worse 
by  certain  articles  of  diet,  especially  eggs 
and  fish.  These  invariably  brought  out  a 
rash,  of  urticarial  type,  so  far  as  I  could  learn, 


IO8  THYROID    THERAPY 

though  I  never  saw  it,  and  as  a  matter  of 
course  these  articles  had  been  long  excluded 
from  his  diet.  Now  the  whole  group  of 
symptoms  in  this  case  presented  a  remarkable 
contrast  to  the  clinical  aspect  of  thyroid  de- 
ficiency, and  I  think  one  might  fairly  infer 
that  thyroid  activity  was  certainly  in  excess 
of  the  normal.  I  am  sorry  to  say  that  the 
results  of  treatment  were  too  conflicting  to 
make  satisfactory  deductions.  But  an  in- 
cidental attack  of  influenza,  accompanied  by 
vomiting  and  diarrhoea,  with  passage  of  mucus 
and  blood,  and  of  such  severity  as  to  necessi- 
tate the  services  of  a  trained  nurse  cured  his 
ezcema  temporarily.  During  the  illness  he 
was  fed  on  Panopepton  and  sherry  whey,  his 
medicine  for  the  most  part  consisting  of  mist, 
cretae.  With  Benger's  food  and  a  gradual 
return  to  his  ordinary  diet,  the  eczema  again 
broke  out,  and  a  few  weeks  afterwards  was 
worse  than  ever.  So  far  as  the  eczema  was 
concerned  thyroid  treatment  was  a  failure,  but 
the  eczema  appeared  worse  when  thyroidism 
was  either  excessive  or  insufficient,  and  was 
less  troublesome  when  a  happy  medium  was 
maintained.  His  eczema  only  got  well  when 
his  intestine  was  thoroughly  empty,  the  child 
remaining  in  bed  and  living  only  on  small 
quantities  of  the  most  digestible  food.  This 
was  the  only  time  when  I  succeeded  in  getting 


THYROID    AND    ECZEMA  IOQ 

a  pulse  count  of  less  than  90,  and  I  think  one 
might  fairly  assume  that  there  was  a  period 
of  thyroid  depression  after  this  acute  attack. 
That  this  was  so  we  had  further  evidence 
shortly  afterwards,  for  he  wetted  the  bed  on 
several  occasions.  But  in  spite  of  this  the 
eczema  had  returned  with  convalescence,  and 
though  the  administration  of  thyroid  speedily 
stopped  the  enuresis  and  improved  his  general 
health,  his  eczema  got  steadily  worse.  The 
upshot  of  it  all  was  that  eczema  was  bad  during 
a  period  of  thyroid  hyperactivity,  and  also 
during  a  time  of  thyroid  depression. 

The  conclusion  which  I  was  bound  to  come 
to  in  this  case  was,  that  eczema  was  neither 
cause  nor  result  of  thyroid  activity,  though 
probably  some  toxin  which  was  responsible 
for  the  eczema  incidentally  stimulated  the 
thyroid  gland,  which  in  this  case  was  able  to 
respond,  producing  rather  remarkable  results 
in  the  growth  of  the  child  both  physically 
and  mentally.  It  is  equally  evident  that  a 
different  result  might  have  been  produced, 
namely,  thyroid  exhaustion,  and  therefore  it 
may  often  happen,  that  an  individual  who 
suffers  from  eczema  may  have  become  a 
thyroid  deficient,  and  the  administration  of 
thyroid  would  in  such  a  case  be  of  immense 
advantage,  possibly  assisting  the  organism  to 
such  an  extent  that  the  eczema  might  get  well, 


I  IO  THYROID    THERAPY 

though  in  this  particular  case  neither  the 
patient's  own  ample  secretion  nor  an  artificial 
supply  proved  effective.  As  to  the  effect  of 
individual  drugs,  it  is  still  harder  to  draw 
conclusions,  because  results  obtained  might 
have  depended  on  other  factors.  But  parti- 
cular care  was  taken  not  to  alter  the  local 
treatment,  or  the  diet,  when  attempting  to 
gauge  the  effect  of  any  particular  drug.  Never- 
theless, the  following  conclusions  must  not  be 
taken  as  final,  though  the  evidence  was  care- 
fully weighed.  Calcium  lactate  given  three 
times  a  day  for  two  days  in  ic-grain  doses 
was  beneficial  to  the  eczema.  If  continued 
for  more  than  two  days  it  did  harm,  and 
equally,  continuous  small  doses  of  calcium 
lactate  did  harm.  Calcium  iodide  caused  an 
immediate  aggravation  of  the  eczema.  Arsenic 
was  not  given  a  prolonged  trial,  but  on  the 
whole  appeared  to  have  an  unfavourable 
influence.  Thymus  at  first  gave  good  results, 
but  was  disappointing,  The  eczema  certainly 
improved  at  first,  and  the  bowels  became 
constipated.  The  child  remained  thirsty.  He 
complained  that  his  nose  had  become  stuffy 
and  his  tonsils  began  to  enlarge.  This, 
unless  mere  coincidence,  obviously  was  com- 
bating the  thyroid  secretion,  either  by  antago- 
nism or  inhibition,  and  was  tried  for  a 
fortnight.  At  the  end  of  that  time  he  was 


THYROID   AND    ECZEMA  I  I  I 

not  so  well  in  general  health,  and  eczema 
began  to  get  steadily  worse  again.  So 
thymus  was  dropped.  The  dose  used  was 
equivalent  to  2^  grains  of  fresh  thymus  three 
times  a  day.  Then  a  change  in  the  diet  was 
prescribed,  and  he  was  put  on  a  diet  devoid 
of  milk,  cream,  butter  or  animal  fat,  similar 
to  that  already  mentioned  in  the  case  of 
Graves's  disease.  This  was  undoubtedly 
beneficial  to  the  eczema.  It  did  not  appear 
to  hurt  the  child,  though  obviously  it  is 
contrary  to  all  our  preconceived  notions  of 
what  a  child's  food  ought  to  be.  He  was 
allowed  fruit,  vegetables,  lean  meat  and  soups. 
His  weight  altered  very  little,  showing  first 
a  gain  of  4  ounces,  and  ultimately  a  loss  of  9 
ounces  during  eighteen  days  of  this  diet. 
During  this  time  he  was  very  well  in  general 
health,  appetite  good,  bowels  inclined  to  be 
constipated.  His  pulse  on  one  occasion  dropped 
to  99.  At  the  end  of  the  eighteenth  day,  how- 
ever, he  fell  a  victim  to  influenza,  as  already 
mentioned,  and  with  further  evidence  that  the 
thyroid  was  not  -responsible  for  his  eczema, 
either  by  faults  of  omission  or  commission, 
there  was  no  justification  for  returning  to  this 
abnormal  diet.  The  moral  of  the  whole  case 
is  that  thyroid  activity  is  Nature's  method  of 
dealing  with  certain  toxins  (which  in  this  case 
were  the  cause  of  eczema),  and  therefore  in 


I  I  2  THYROID    THERAPY 

some  cases  where  the  toxins  have  gained  the 
upper  hand,  the  thyroid  secretion  is  possibly 
inadequate  and  may  be  usefully  supplemented. 
This  is  of  course  the  rationale  of  the  thyroid 
treatment  of  rheumatoid  arthritis,  which  is 
probably  due  to  toxins  of  intestinal  origin. 
Other  debilitating  influences  have  frequently 
been  noted.  These  may  very  well  induce 
thyroid  exhaustion  and  so  allow  full  play  to 
toxins,  which  might  be  efficiently  dealt  with 
by  an  adequate  thyroid.  It  is  interesting  to 
note  that  Garrod  relies  largely  on  iodide  of 
iron  in  this  complaint,  iron  and  iodide  both 
being  drugs  which  stimulate  or  assist  thyroid 
activity,  whilst  other  authorities  rely  on  the 
intestinal  disinfectant  guaiacol  carbonate.  In 
view  of  these  facts,  it  seems  highly  probable 
that  there  may  often  occur  paroxysmal  periods 
of  thyroid  activity,  or  exhaustion  brought 
about  by  the  vicissitudes  of  life.  I  am 
disposed  to  think  that  acne  spots  of  youth  are 
probably  due  to  hyper-activity  of  the  thyroid 
gland.  All  honour  to  the  staphylococcus  and 
acne  bacillus,  but  a  few  doses  of  iodide  or 
bromide  of  potassium  will  often  produce  a 
similar  result.  These  spots  are  essentially  a 
feature  of  youth,  and  have  a  tendency  to 
disappear  as  the  adolescent  develops  into  the 
adult,  that  is  to  say,  they  are  most  prone  to 
occur  during  the  periods  when  there  is  a  big 
reflex  discharge  of  thyroid  activity. 


THYROID    AND    ECZEMA  113 

Dr.  Arnold  Lorand  tells  us  (in  an  article 
published  in  the  Lancet,  November  9,  1907) 
that  he  was  particularly  subject  to  acne  during 
ten  months  when  he  was  experimentally  taking 
thyroid.  The  little  boy  whose  case  I  have 
just  described  was  also  very  subject  to  isolated 
large  acne  spots,  or  small  boils,  according  to 
the  nomenclature  one  may  prefer.  May  they 
not  be  caused  by  excess  of  iodine  poured  into 
the  system  by  the  thyroid  ?  It  is  a  significant 
fact  that  arsenic  is  the  best  remedy  for  acne 
(except,  of  course,  vaccine) ;  arsenic  here  acting 
as  an  antidote  for  thyroid  secretion.  One  diffi- 
culty in  this  view  is  that  Graves's  disease  does 
not  usually  present  the  worst  cases  of  acne, 
though  a  minor  tendency  to  acne  is  often 
present.  But  it  may  be  merely  a  question  of 
dosage.  One  remedy  for  the  symptoms  of 
iodism,  if  they  occur  during  the  administration 
of  potassium  iodide,  is  to  double  the  dose.  In 
Graves's  disease  the  dose  of  thy ro -iodine  is 
probably  much  more  than  doubled.  Also  it 
may  be  that  the  staphylococci  of  suppurative 
acne  do  not  thrive  any  better  than  other 
disease  germs  do,  under  the  influence  of  the 
prolonged  thyroid  activity  of  Graves's  disease. 
The  victims  of  Graves's  disease  are  usually 
remarkably  immune  from  ordinary  infections. 
It  is  highly  probable,  however,  that  in  the 
adolescent  cases  of  which  we  are  speaking, 
8 


114  THYROID    THERAPY 

thyroid  activity  is  paroxysmal  and  irregular 
rather  than  continuous,  being  modified,  among 
other  circumstances,  by  the  irregularities  of 
sexual  development.  Possibly  paroxysmal 
thyroid  activity,  and  resulting  temporary 
exhaustion,  may  be  responsible  for  some  of 
the  curious  anomalies  with  which  we  are  some- 
times confronted.  A  patient  whose  total  thy- 
roid secretion  is  apparently  plus,  will  from  time 
to  time  exhibit  some  symptom  which  we  are 
accustomed  to  associate  with  the  minus  condi- 
tion. Even  Graves's  disease  presents  some 
anomalies  of  this  kind,  and  the  fact  that  some 
cases  end  in  myxcedema  or  complete  thyroid 
exhaustion  lends  support  to  the  above 
explanation.  Thirst,  ravenous  appetite,  loss 
of  hair,  dental  caries,  various  pigmentary 
changes  in  the  skin,  urticaria,  a  constant 
sensation  of  fatigue  and  inability  for  exertion, 
haemorrhages,  disorders  of  menstruation  are 
all  symptoms  that  may  be  met  with  in  Graves's 
disease  (Allbutt's  "  System  of  Medicine  "),  and 
I  have  seen  all  these  symptoms  definitely 
improve  in  various  thyroid  deficients  under 
the  influence  of  thyroid  medication.  In  the 
case  of  dental  caries,  of  course,  it  is  needless 
to  say  that  carious  teeth  did  not  improve,  but 
in  these  children,  though  the  deciduous  teeth 
had  been  very  bad,  the  permanent  teeth  showed 
every  sign  of  being  good.  A  tempting  explana- 


THYROID    AND    ECZEMA  115 

tion  of  these  anomalies,  when  met  with  in 
Graves's  disease,  is  to  suppose  that  in  spite  of 
continued  thyroid  hyper-activity  the  secretion 
may  have  deteriorated  in  some  of  its  properties, 
and  thus  given  rise  to  some  of  the  symptoms 
which  we  are  accustomed  to  associate  with 
thyroid  inadequacy.  I  have  seen  chilblains 
occur  in  a  patient  recovering  from  Graves's 
disease,  and  speedily  relieved  them  with  a 
prescription  containing  calcium  lactate,  liquor 
arsen.  rrtiv.  and  gr.  i.  of  thyroid,  taken  three 
times  a  day.  But  the  symptoms  of  Graves's 
disease  were  increasingly  aggravated  each  day 
that  the  patient  took  this  mixture,  and  in  three 
days  it  had  to  be  left  off. 


n6 


CHAPTER   X. 
Thyroid  and  Arsenic. 

ARSENIC  is  a  drug  which  undoubtedly  has  a 
special  influence  on  thyroid  activity.  Precisely 
what  that  influence  may  be  is  a  matter  that 
demands  careful  consideration.  Many  obser- 
vations have  been  made  on  the  subject,  and 
the  results  appear  somewhat  conflicting.  I 
have  seen  it  stated  that  arsenic  is  a  normal 
ingredient  of  the  thyroid  gland,  and  that  it 
is  sixteen  times  as  plentiful  in  the  human 
thyroid  as  in  that  of  the  sheep.  But  there 
are  obvious  difficulties  in  accepting  a  statement 
of  this  sort,  in  the  face  of  the  fact  that  expert 
analysts,  accustomed  to  dealing  with  thyroid 
substance  for  the  market,  failed  to  find  any 
trace  of  arsenic  when  testing  a  large  quantity 
of  sheep's  thyroid.  Arsenic,  as  is  well  known, 
has  a  great  tendency  to  remain  in  the  body 
a  long  time  after  it  has  been  taken  by  the 
mouth,  and  may  readily  be  detected  in  a 
corpse  long  after  burial.  Now,  most  human 
beings  take  arsenic  at  some  time  during  their 
lives,  and  town  dwellers  probably  inhale  a 


THYROID    AND    ARSENIC  I  I  7 

small  quantity  daily  in  our  smoky  atmosphere  ; 
not  to  mention  the  amount  we  used  to  take 
in  our  beer,  and  probably  also  in  many  other 
ways  of  which  we  know  nothing.  Therefore, 
when  analysis  detects  infinitesimal  quantities 
of  arsenic  in  the  thyroid  or  any  other  organ 
(and  it  has  been  found  in  most  organs),  it 
is  somewhat  difficult  to  say  whether  it  is 
proper  to  the  gland  or  merely  retained  there. 
One  might  equally  well  say  that  carbon  is  a 
normal  ingredient  of  the  human  lungs.  In 
a  sense  this  is  true,  inasmuch  as  it  is  in- 
variably present.  Further,  seeing  that  arsenic 
has  a  special  influence  on  thyroid  activity,  it 
is  not  unlikely  that  the  gland  may  possess  a 
selective  action  for  arsenic,  and  so  retain  more 
of  it  than  is  the  case  with  other  organs.  The 
very  difference  in  the  amount  of  arsenic  found 
in  the  analyses  of  the  human  and  the  sheep's 
thyroid  makes  it  all  the  more  probable  that 
the  matter  depends  largely  on  food  and  chance 
circumstances.  The  sheep,  living  in  the 
country  for  the  most  part,  are  less  likely  to 
obtain  arsenic  from  the  smoky  atmosphere. 
And,  on  the  other  hand,  the  food  of  man, 
which  is  so  largely  manufactured  and  artificial, 
has  infinitely  more  chance  of  getting  contam- 
inated with  arsenic  than  that  of  the  sheep. 
But  even  sheep  are  to  some  extent  artificially 
fed,  and  arsenic  may  sometimes  find  its  way 


Il8  THYROID    THERAPY 

to  their  thyroid  glands  in  some  purely  acci- 
dental manner,  which  might  readily  occur  if 
arsenic  were  an  ingredient  of  a  sheep  dip  or 
any  preparation  used  for  other  purposes  in 
tending  the  flock.  But  perhaps  it  is  not  a 
matter  of  great  practical  importance  whether 
arsenic  is  a  normal  ingredient  of  the  thyroid 
gland  or  not,  though  a  knowledge  of  this 
matter  might  help  to  decide  some  other  pro- 
blems. I  believe  it  is  generally  held  that  it 
is  a  normal  ingredient,  in  extremely  minute 
quantities.  In  any  case,  it  seems  highly  pro- 
bable that  arsenic  owes  much  of  its  therapeutic 
effect  to  its  action  on  the  thyroid.  Minute 
doses  increase  the  rapidity  of  the  pulse.  That 
may  well  be  by  neutralizing  a  small  quantity 
of  thyroid  secretion  and  thereby  stimulating 
an  increased  production.  Large  doses  diminish 
pulse  frequency,  which  may  well  be  by  neutral- 
izing a  larger  quantity  of  thyroid  secretion 
and  for  the  time  being  depriving  the  body  of 
it.  It  would  be  interesting  to  have  some 
reports  on  the  condition  of  thyroid  secretion 
in  the  arsenic  eaters  of  Styria.  Their  ability 
to  undergo  prolonged  exertion  without  fatigue 
might  possibly  be  due  to  special  excellence  of 
their  thyroid  glands,  whose  powers  of  secretion 
might  be  augmented  by  this  daily  course  of 
arsenic.  It  is  well  known  that  muscular  fatigue 
is  very  rapidly  induced  in  thyroid  inadequates, 


THYROID    AND    ARSENIC  IIQ 

and  also  that  muscular  exercise  depresses 
thyroid  activity.  The  deduction  is,  that  it  is 
the  duty  of  the  thyroid  gland,  among  other 
things,  to  eliminate  fatigue  products.  There- 
fore, the  better  the  thyroid  the  less  fatigue. 
Why  then  cannot  the  victims  of  Graves's  disease 
undergo  fatigue?  The  answer  appears  to  be 
that  in  their  case  the  thyroid  is  already  work- 
ing at  full  pressure,  and  any  cause  which  called 
for  further  activity  would  naturally  make  the 
patient  worse.  As  a  matter  of  fact,  even  in 
Graves's  disease  there  is  ample  evidence  that 
muscular  exercise  does  increase  thyroid  activity, 
aggravating  the  symptoms  to  such  an  extent 
that  the  patient  is  bound  to  desist.  But  arsenic 
has  long  been  a  standard  drug  in  the  treatment 
of  Graves's  disease.  Is  this  by  neutralizing 
thyroid  secretion  ?  or  does  it  improve  the 
general  thyroid  tone  by  giving  gentle  exercise, 
in  the  same  way  that  graduated  exercise  may 
improve  irregular  and  failing  hearts  ?  Arsenic 
is  also  the  standard  drug  for  lymphadenoma, 
psoriasis,  chronic  eczema  and  acne,  all  of 
which  conditions  at  times  appear  to  be  related 
to  thyroid  activity.  Thyroid  medication  has 
proved  successful  in  cases  of  the  first  three 
disorders,  so  the  utility  of  arsenic  in  these 
complaints  might  be  explained  on  the  ground 
that  it  stimulates  thyroid  secretion,  or  perhaps 
one  ought  to  say,  improves  thyroid  capacity. 


120  THYROID    THERAPY 

The  power  of  arsenic  in  preventing  acne, 
whether  induced  by  bromides,  iodides,  or  of 
obscure  origin,  is  difficult  to  explain,  specially 
in  view  of  the  fact  that  thyroid  feeding  may 
be  productive  of  acne.  The  last  factor  and 
he  utility  of  arsenic  in  Graves's  disease  suggest 
that  the  drug  is  antagonistic  to,  or  neutralizes, 
thyroid  secretion.  Further,  some  observers 
find  that  the  unpleasant  symptoms  of  thy- 
roidism  may  be  prevented  by  prescribing 
arsenic  and  thyroid  gland  substance  together. 
Unless  this  is  to  be  described  as  irrational 
pharmacy,  the  administration  of  substances 
having  opposite  effects,  we  must  find  some 
rational  explanation. 

The  only  explanation  I  can  think  of  which 
fits  the  case,  is  that  the  arsenic  when  adminis- 
tered takes  charge  of  the  iodine  (possibly 
by  chemical  combination),  and  so  acts  as  a 
sort  of  guardian  or  trustee  for  the  affairs  of 
the  thyroid,  serving  out  thyro-iodine  with  a 
careful  hand.  Thus,  under  the  influence  of 
arsenic  the  iodine  is  not  allowed  to  be  wasted 
and  excreted  by  the  skin  in  acne  pustules. 
There  is  less  iodine  allowed  to  flood  the 
system  in  Graves's  disease,  naturally  resulting 
in  improvement.  By  careful  management 
there  is  a  supply  of  reserve  iodine  kept  in 
the  thyroid  store  for  emergencies,  such  as 
the  prolonged  muscular  exertion  of  the  Styrian 


THYROID    AND    ARSENIC  121 

arsenic  eaters.  Similarly,  thyroid  efficiency 
may  be  increased,  and  the  organism  enabled 
to  deal  with  eczema,  psoriasis,  or  lymphade- 
noma.  And  when  additional  thyro-iodine  is 
fed  into  the  body,  the  arsenic  immediately 
assumes  control  and  doles  it  out  with  careful 
hand,  so  preventing  symptoms  of  "thyroidism." 
This  hypothesis  would  also  account  for  a  fact 
which  I  have  noticed  several  times,  namely, 
that  goitres  decrease  more  rapidly  under  the 
influence  of  thyroid  feeding  alone,  than  when 
arsenic  and  thyroid  substance  are  administered 
together.  The  immediate  effect  of  administer- 
ing arsenic  with  thyroid  is  equivalent  to  lessen- 
ing the  dose  of  thyroid,  because  the  arsenic, 
so  to  speak,  ties  up  some  of  the  available 
iodine,  however  badly  this  may  be  wanted 
in  the  system.  At  the  same  time,  it  seems 
to  stimulate  the  thyroid  gland  to  greater 
exertions,  and  in  consequence  one  sometimes 
sees  an  actual  enlargement  of  the  goitre  under 
its  influence.  There  are  obvious  objections 
to  stimulating  an  enlarged  thyroid,  and  for  this 
reason  one  would  prefer  not  to  give  either 
arsenic  or  iodine  to  patients  with  goitre,  as 
a  general  rule.  Personally,  I  would  endeavour 
to  do  all  the  work  of  the  enlarged  gland 
and  let  it  lie  dormant  and  atrophy.  When 
it  has  shrunken  to  due  proportions  one  can 
stimulate,  if  necessary,  without  fear  of  launching 


122  THYROID    THERAPY 

the  patient  into  potential  Graves's  disease. 
One  must  however  bear  in  mind  the  possibility 
that  there  may  be  an  actual  shortage  of  iodine 
in  the  system,  and  therefore  an  occasional 
dose,  say  a  one-grain  iodoform  pill,  might 
be  administered  with  advantage.  This  dose 
may  appear  ridiculously  small,  but  in  reality 
is  not  so.  It  has  been  shown  that  iodoform 
has  an  even  more  powerful  influence  than 
potassium  iodide  on  thyroid  activity.  Iodo- 
form contains  more  iodine  than  potassium 
iodide,  a  single  grain  of  which  represents 
approximately  the  amount  of  iodine  contained 
in  thirty-eight  grains  of  thyroid  tabloid.  I 
had  one  patient,  the  subject  of  goitre,  who 
showed  marked  improvement  after  the  omis- 
sion of  the  one  grain  of  potassium  iodide, 
and  one  minim  of  liquor  arsenicalis  which  had 
been  administered  with  i£  grains  of  thyroid 
three  times  a  day.  The  thyroid  was  continued 
alone  and  followed  by  a  much  more  rapid 
increase  of  weight  and  sense  of  well-being, 
and  a  more  rapid  decrease  of  the  parenchy- 
matous  goitre.  This  particular  patient  had  a 
large  goitre  with  a  tendency  to  hyper-secretion. 
If  it  be  decided  to  give  iodine  in  goitre,  small 
doses  are  better  than  large.  Chemically,  a 
small  dose  is  fully  adequate,  and  the  thyroid 
has  the  chance  of  helping  itself  to  all  its  wants, 
and  clinically  it  has  been  shown  that  small 


THYROID   AND    ARSENIC  123 

doses  are  actually  more  potent  than  large. 
When  large  doses  are  administered,  probably 
the  iodide  acts  more  as  an  irritant,  and  more 
rapidly  sets  in  motion  the  apparatus  for  its 
own  elimination,  which  is  chiefly  done  by  the 
kidneys.  There  is  also  the  possibility  that 
it  fatigues  and  exhausts  the  thyroid  by  over 
stimulation,  so  that  actually  a  less  quantity 
may  be  absorbed.  Probably,  this  is  why 
small  doses  of  iodides  are  more  prone  to  cause 
iodism  than  is  the  case  with  large  doses. 
The  small  doses  being  administered  to  the 
body  via  the  thyroid  gland  cause  many  of 
the  well-known  symptoms  associated  with 
hyper-thyroidism,  headache,  quick  pulse  and 
looseness  of  the  bowels.  But  when  larger 
doses  are  given  the  kidneys  get  to  work  and 
eliminate  it  rapidly,  so  that  the  thyroid  and 
other  organs  are  not  so  troubled,  and  symptoms 
of  iodism  are  absent.  It  would  appear  prob- 
able that  those  who  are  hypersensitive  to  the 
administration  of  iodine  are  the  possessors  of 
unusually  active  thyroid  glands,  and  this  in- 
ference may  prove  of  value  in  giving  one  a 
fuller  understanding  of  the  patient.  Persons 
suffering  from  Graves's  disease  have  been 
observed  to  become  worse  under  the  in- 
fluence of  sea  air,  and  this  fact  has  been 
explained  by  the  assumption  that  the  iodine 
present  in  sea  air  was  sufficient  to  aggravate 


124  THYROID   THERAPY 

the  symptoms.  Considering  the  very  minute 
quantity  of  iodine  present  in  what  may  be 
considered  a  normal  daily  secretion  of  thyro- 
iodine,  this  theory  is  by  no  means  so  ridicu- 
lous as  it  seems.  But,  on  the  other  hand,  it 
has  been  noticed  that  neurasthenics  as  a  class 
do  not  do  well  by  the  seaside,  so  it  may  be 
the  neurasthenic  element  of  Graves's  disease 
which  is  unfavourably  influenced,  rather  than 
the  iodine  factor.  Trousseau  found,  however, 
that  iodides  produced  acute  paroxysms  of  the 
disease.  In  this  connection  it  is  worth  con- 
sidering all  complaints  which  are  powerfully 
affected  by  any  form  of  iodine  or  of  arsenic,  to 
see  whether  such  action  may  be  influenced  by 
thyroid  secretion.  Now  mention  has  already 
been  made  of  the  value  of  arsenic  in  lympha- 
denoma,  and  it  has  been  authoritatively  stated 
that  arsenic  is  the  only  drug  which  has  any 
influence  on  this  disease.  But  in  the  more 
modern  light  of  Dr.  John  Orr's  success  with 
thyroid,  I  have  just  suggested  that  this  bene- 
ficial action  of  arsenic  in  lymphadenoma  may 
be  at  least  partly  due  to  the  special  action  of 
the  drug  on  the  thyroid  gland,  though  one 
must  not,  of  course,  lose  sight  of  the  effect  of 
arsenic  on  particular  micro-organisms. 

Most  observers  seem  to  be  agreed  that 
arsenic  stimulates  thyroid  activity,  though 
the  conclusion  to  be  drawn  from  the  various 


THYROID    AND    ARSENIC  125 

uses  of  arsenic  which  I  have  enumerated  \/' 
would  rather  be  that  on  the  whole  arsenic 
controls  thyroid  activity,  though  it  may  increase 
thyroid  capacity.  Perhaps  it  is  not  fair  to 
draw  conclusions  from  the  action  of  arsenic 
in  diseases  like  eczema  and  psoriasis,  owing 
to  the  special  influence  of  arsenic  on  the  skin  ; 
though  even  that  might  be  by  way  of  the 
thyroid  gland.  It  is  probable  also  that  arsenic 
has  its  own  controlling  influence  on  lymphatic 
secretion  generally,  being  the  only  drug  of 
value  in  lymphatic  leukaemia,  as  well  as  in 
lymphadenoma.  And  this  influence  might 
also  play  a  part  in  the  effect  of  arsenic  on 
Graves's  disease,  in  which  malady,  as  already 
mentioned,  the  lymphatic  glands  may  have  a 
share.  But  there  is  another  most  interesting 
use  of  arsenic  in  medicine,  namely,  in  treating 
consumption.  Various  authorities  are  agreed 
that  Fowler's  solution  is  probably  the  most 
generally  useful  remedy  in  this  disease.  And, 
on  the  other  hand,  Leonard  Williams  says 
that  for  some  reason  thyroid  is  very  badly 
borne  by  consumptives,  and  hence  must  be 
given  with  great  caution,  or  not  at  all,  where 
there  is  any  suspicion  of  this  complaint.  It 
appears  in  some  cases  to  do  very  definite 
harm,  though  in  others  it  has  been  given  with 
impunity,  and  benefit  to  the  condition  for 
which  it  was  administered.  Recently,  cases 


126  THYROID    THERAPY 

of  inoperable  cancer  have  been  considerably 
benefited  by  thyroidectomy.  Stuart  Low,  the 
author  of  some  such  successful  operations,  finds 
evidence  of  excessive  thyroid  activity  both  in 
carcinoma  and  tuberculosis,  and  speaks  of  the 
thyroid  as  the  fly-wheel  of  body  growth  and 
metabolism.  If  the  fly-wheel  revolves  too 
fast,  excessive  metabolism  leading  to  wasting 
will  naturally  result.  This  is  the  argument 
against  the  administration  of  thyroid  in  tuber- 
culosis, and  incidentally  in  cancer.  It  may  be 
that  the  beneficial  influence  of  arsenic  in 
tuberculosis  is  due  to  its  restraining  action 
on  the  thyroid.  The  same  factor  would 
account  for  the  fattening  action  of  arsenic, 
and,  perhaps,  also  for  the  good  effect  of 
calcium  in  tubercle.  It  must  be  noted  that 
although  the  immediate  effect  of  arsenic 
probably  is  to  stimulate  thyroid  activity,  it 
has  to  be  administered  for  extended  periods 
to  produce  its  therapeutic  effect  in  the  diseases 
for  which  it  is  used  as  a  remedy,  such  as 
Graves's  disease,  lymphadenoma,  tubercle, 
pernicious  anaemia,  psoriasis,  chronic  eczema, 
and  so  forth  ;  and  it  is  also  only  by  prolonged 
administration  that  the  Styrian  peasants  are 
able  to  gain  their  immunity  from  fatigue. 
Except  for  the  case  of  the  latter,  one  would 
be  tempted  to  say  that  the  action  of  arsenic 
on  the  thyroid  is  to  all  intents  and  purposes 


THYROID    AND    ARSENIC  127 

suppression,  and  that  though  the  thyroid  may 
at  first  attempt  to  resist  (manifesting  symp- 
toms of  activity),  very  soon  the  arsenic  gains 
the  upper  hand,  and  exercises  mainly  a  con- 
trolling influence.  If  we  add  that  arsenic 
increases  thyroid  capacity,  I  think  this  ex- 
planation will  fit  all  cases,  though  I  do  not 
necessarily  wish  to  infer  that  arsenic  has  no 
action  apart  from  thyroid  influence.  Arsenic 
has  been  administered  for  epithelioma,  rodent 
ulcer,  and  even  scirrhus  (Ringer  and  Sains- 
bury).  Surely  this  was  a  step  in  the  dark 
towards  Stuart  Low's  thyroidectomy.  The 
curious  thing  is  that  in  tubercle  and  cancer 
Nature's  attempts  to  fight  the  toxins  (which 
she  does  by  instituting  special  thyroid  activity, 
as  we  can  demonstrate  in  the  post-mortem 
room)  should  be  not  only  futile,  but  positively 
injurious.  Probably  the  proper  way  to  regard 
the  matter  is  that  up  to  a  certain  point,  namely, 
in  the  early  stages,  thyroid  activity  is  bene- 
ficial, and  may  even  help  to  attain  a  successful 
issue  in  those  cases  in  which  the  battle  is  won. 
But  the  thyroid  does  not  know  when  it  is 
beaten.  It  is  no  use  to  bring  up  the  whole  of 
our  resources  against  overwhelming  odds.  It 
only  makes  defeat  more  signal,  and  makes 
any  ultimate  rally  impossible.  Arsenic  is  also 
4 'often  serviceable  in  rheumatoid  arthritis," 
says  Ringer  and  Sainsbury's  "  Handbook  of 


128  THYROID    THERAPY 

Therapeutics."  "All  forms  may  be  cured,  but 
it  sometimes  fails,  and  indications  for  its  em- 
ployment are  unknown."  One  might  suggest 
that  it  succeeds  in  those  cases  in  which  the 
thyroid  is  able  to  make  an  adequate  response 
to  arsenical  stimulation.  The  same  authorities 
state  that  arsenic  makes  the  bones  heavier 
and  more  compact.  It  is  probable  that  it 
assists  the  thyroid  in  the  duty  of  calcifica- 
tion. Phosphorus  has  the  same  effect  so  far 
as  the  bones  are  concerned,  and  possibly  for 
the  same  reason.  The  general  action  of  phos- 
phorus in  medicinal  doses,  and  its  value  in 
rickets,  both  suggest  that  it  also  has  consider- 
able influence  on  thyroid  activity.  There  is 
another  disease  for  which  arsenic  is  a  standard 
remedy,  namely,  asthma.  And  in  treating 
this  complaint,  iodides  have  a  place  of  perhaps 
equal  importance  with  arsenic. 

In  view  of  these  facts  it  is  worth  while  to 
see  what  influence  thyroid  has  on  asthma.  I 
feel  sure  that  I  have  read  somewhere  that 
asthma  is  one  of  the  many  possible  results  of 
thyroid  deficiency,  but  cannot  now  trace  the 
source  of  this  statement.  I  have  treated 
several  patients  on  this  supposition  with 
varying  success.  Asthma  of  course  depends 
not  infrequently  on  nasal  conditions,  which 
again  are  frequently  the  result  of  or  associated 
with  adenoids.  Here  is  obviously  an  argument 


THYROID    AND    ARSENIC  I  29 

that  thyroid  treatment  will  do  good.  There  is 
also  a  widely  prevalent  (but  probably  erroneous) 
notion,  that  asthma  is  due  to  a  sort  of  urticarial 
condition  of  the  bronchial  mucosa,  which  in 
itself,  or  by  provoking  spasm  of  the  bronchial 
muscles,  causes  the  paroxysm.  The  supposed 
urticarial  condition  might  very  well  yield  to 
calcium  salts  and  thyroid,  one  or  both.  But, 
as  pointed  out  in  a  recent  article  in  the 
Practitioner,  asthma  cannot  be  due  to  obstruc- 
tion of  the  bronchial  tubules  by  any  urticarial 
swelling,  inasmuch  as  during  the  paroxysm  of 
asthma  the  sufferer  is  able  to  inspire  air  freely, 
but  the  difficulty  is  an  expiratory  one.  Hence, 
the  chest  gets  into  a  highly  distended 
emphysematous  condition  and  the  air  wheezes 
out  slowly,  If  the  difficulty  were  due  to 
mechanical  obstruction  by  turgid  mucous 
membrane,  there  would  obviously  be  equal 
difficulty  during  inspiration  and  expiration. 
The  difficulty  therefore  depends  on  some  more 
complex  nervous  mechanism,  which  apparently 
induces  spasm  as  soon  as  an  expiratory  effort 
is  made,  but  leaves  the  inspiration  free.  Such 
a  condition  may  be  compared  with  sobbing, 
which  is  the  physiological  opposite.  A  sob 
consists  of  a  series  of  short  spasmodic  inspir- 
atory  efforts,  which  may  be  followed  by  a 
prolonged  free  expiration  or  sigh.  Again  a 
laugh  is  a  series  of  spasmodic  expiratory 
9 


130  THYROID    THERAPY 

efforts,  accompanied  by  phonation  or  not, 
according  as  the  vocal  cords  are  brought  into 
play  or  otherwise.  Curiously,  hilarious  laughter 
may  provoke  a  spasm  of  asthma,  as  I  have 
witnessed  in  a  susceptible  subject.  But  though 
the  paroxysm  of  asthma  cannot  be  due  to 
mechanical  obstruction  caused  by  an  urticarial 
condition  of  the  mucosa,  it  is  still  possible  that 
such  an  urticarial  condition  may  exist  and  be 
the  starting  point  of  the  nervous  paroxysms. 
Whether  this  be  so  or  not,  it  is  by  no  means 
uncommon  to  meet  with  other  signs  of  thyroid 
deficiency  in  the  victims  of  asthma,  and 
accordingly  appropriate  treatment  will  certainly 
be  beneficial  to  the  patient,  and  in  some  cases 
health  may  be  so  improved  that  the  asthma 
quickly  gets  well.  I  have  had  several  such 
cases,  but  at  the  same  time  it  must  not  be 
expected  that  thyroid  treatment  will  prove  a 
panacea  for  asthma.  On  the  other  hand, 
prolonged  asthma,  like  most  other  depressing 
conditions,  undoubtedly  has  an  unfavourable 
effect  on  thyroid  metabolism,  and  in  such  cases 
attention  to  this  point  has  given  me  striking 
results,  though  as  a  remedy  for  asthma  pure 
and  simple  I  confess  that  thyroid  has  disap- 
pointed me. 


CHAPTER  XL 

The  Influence  of  Salicylates  and  Kindred  Drugs 
on  Thyroid  Activity. 

THIS  subject  involves  of  necessity  some 
consideration  of  thyroid  activity  in  relation  to 
fever.  It  is  a  tempting  theory  that  the 
ordinary  symptoms  of  fever  are  due,  at  least 
in  part,  to  increased  thyroid  activity,  such 
activity  being  one  of  Nature's  methods  of 
dealing  with  toxins  which  may  have  obtained 
access  to  or  been  formed  within  the  body. 
Evidence  in  favour  of  this  supposition  has 
been  supplied  by  Roger  and  Gamier,  who 
found  that  in  acute  infectious  diseases  with 
fever  there  is  increased  thyroid  activity  with 
enlargement  of  the  folliculi,  which  are  filled 
with  a  large  quantity  of  colloid  substance. 
Further,  we  have  ample  evidence  that  thyroid 
exhaustion  is  commonly  manifested  by  clinical 
symptoms  as  a  sequela  of  febrile  diseases. 
Dr.  Arnold  Lorand  has  discussed  the  whole 
matter  in  a  most  interesting  article,  which 
appeared  in  the  Lancet  of  November  9,  1907, 
and  throughout  that  article  he  certainly  cannot 
be  accused  of  under-rating  thyroid  influence. 


132  THYROID    THERAPY 

He  attributes  the  rapid  pulse,  abundant 
perspiration,  polyuria  and  diarrhoea  all  directly 
to  thyroid  influence,  and  quotes  experiments 
to  show  that  the  rise  of  temperature  may  very 
well  be  due  to  the  same  cause.  The  supposi- 
tion is  attended  with  certain  difficulties,  and 
if  we  accept  it  we  shall  be  driven  to  certain 
other  logical  conclusions.  Throughout  we 
shall  take  Graves's  disease  as  our  standard  of 
excessive  thyroid  activity.  Now  the  process 
of  fever  is  not  a  solitary  and  simple  condition, 
but  a  complex  cycle  of  events  which  tends, 
howeve'r,  to  follow  a  fairly  definite  course. 
Accepting  thyroid  activity  as  the  main  factor, 
we  shall  attempt  to  interpret  events  as  we  go 
along.  Firstly,  there  is  a  sensation  of  lassitude 
and  chilliness,  which  is  probably  a  signal  that 
toxins  have  gained  access  to  the  system,  which 
has  used  up  all  the  available  thyroid  secretion 
in  attempting  to  neutralize  them.  And  though 
the  thyroid  sets  to  work  with  all  diligence  to 
make  more,  for  a  time  the  secretion  is 
neutralized  by  the  toxins  as  fast  as  it  can  be 
produced.  Thus,  there  is  a  period  of 
temporary  thyroid  deficiency  in  spite  of  rapid 
production.  The  deficiency  accounts  for  the 
sensation  of  cold,  often  amounting  to  actual 
shivering,  and  also  for  the  constipation  which 
is  so  frequently  present.  It  may  also  account 
for  the  want  of  appetite,  so  often  observable 


THE    INFLUENCE    OF    SALICYLATES  133 

in  patients  who  suffer  from  thyroid  inadequacy, 
and  possibly  even  for  excessive  thirst,  which  I 
have  likewise  often  noticed  in  similar  cases, 
and  have  already  noted  elsewhere.  A  corres- 
ponding point  about  the  thirst  is  that  cold 
water  is  the  drink  preferred  to  any  other,  a 
fact  which  may  be  readily  verified  by  inquiries 
among  half  a  dozen  children  suffering  from 
minor  degrees  of  thyroid  inadequacy.  On  the 
other  hand,  we  must  assume  that  thyroid 
activity  is  in  itself  the  cause  of  the  increased 
pulse  rate  and  rise  of  temperature.  The 
flushed  face,  the  sensation  of  throbbing 
carotids  and  temples,  and  the  consciousness  of 
every  heart-beat,  are  all  familiar  features  both 
in  Graves's  disease  and  fever.  The  tremor 
and  sensation  of  fatigue  will  be  equally 
witnessed  in  both  conditions.  But  as  yet  we 
have  no  sweating,  which  is  almost  invariable 
in  Graves's  disease.  In  fever  this  occurs  later 
and  with  it  the  fall  of  temperature.  On  the 
other  hand,  pyrexia  is  by  no  means  a  constant 
feature  of  Graves's  disease.  Pi  ere  are  two 
difficulties  which  require  careful  handling,  and 
have  possibly  proved  a  stumbling-block  to  some 
who  might  otherwise  have  accepted  this  theory 
before.  The  difficulty  can  be  got  over  by  the 
following  explanation.  A  rise  of  temperature, 
not  necessarily  amounting  to  pyrexia,  is  the 
immediate  effect  of  big  doses  of  thyroid, 


134  THYROID    THERAPY 

whether  administered  by  the  mouth  or  by 
sudden  hyperactivity  of  the  patient's  own  gland. 
Pyrexia  is  prone  to  occur,  when  the  surgeon 
unintentionally  floods  the  system  with  thyroid 
secretion,  by  manipulation  of  the  gland  during 
operation.  But  sweating  only  occurs  when 
the  organism  finds  itself  flushed  with  more 
thyroid  secretion  than  is  required.  Thus  in 
Graves's  disease,  where  secretion  is  in  excess 
all  the  time,  sweating  is  the  rule.  Again 
during  active  exercise  there  is  evidence  of 
increased  thyroid  activity,  shown  by  increased 
pulse  rate  and  flushed  skin,  but  sweating  does 
not  immediately  occur,  perhaps  not  till  secre- 
tion is  in  excess  of  demands,  the  first  supplies 
being  presumably  taken  up  by  fatigue  products. 
And  in  fevers,  when  the  production  of  thyroid 
secretion  exceeds  the  amount  required  to  neu- 
tralize the  toxins,  sweating  occurs,  followed 
by  a  fall  of  temperature.  The  improved  con- 
dition of  the  patient  is  fully  in  accordance 
with  this  view.  The  fall  of  temperature  is 
partly  regulated  by  evaporation  of  sweat,  but 
probably  depends  still  more  on  reflex  inhibition 
or  temporary  exhaustion  of  the  thyroid  gland? 
which  has  now  succeeded  in  the  task  it  set  out 
to  perform,  namely,  neutralizing  the  toxins, 
producing  secretion  enough  and  to  spare.  The 
temperature  often  falls  without  the  occurrence 
of  sweating,  and  will  frequently  remain  low, 


THE    INFLUENCE    OF    SALICYLATES  135 

with  a  correspondingly  diminished  pulse  rate, 
for  several  days.  The  duration  and  severity 
of  the  symptoms  will  naturally  depend  on  the 
amount  of  toxins  produced,  and  the  capacity 
of  the  thyroid  to  neutralize  them  in  a  longer 
or  shorter  time.  The  dose  may  of  course  be 
more  than  the  thyroid  can  deal  with,  or  hyper- 
pyrexia  may  result  from  excessive  thyroid 
activity.  Such  contingencies  do  not  affect 
the  argument  as  a  whole,  and  it  may  be 
fairly  claimed  that  the  position  is  at  least  not 
untenable. 

Similarly  it  has  been  argued  that  salicylates 
(and  presumably  other  antipyretics)  produce 
their  effects  by  thyroid  stimulation.  A 
moderate  dose  of  salicylate  of  soda  in  the 
healthy  subject  produces  (according  to  Mitchell 
Bruce)  "  increased  cardiac  action,  flushing  and 
warmth  of  the  surface  with  perspiration,"  and 
other  symptoms  which  are  to  some  extent 
peculiar  to  the  drug.  So  far,  this  may  very 
well  be  explained  on  Dr.  Arnold  Lorand's 
assumption  that  salicylate  of  soda  acts  by 
stimulating  thyroid  activity.  And  in  fevers, 
when  thyroid  activity  is  already  high,  a  dose 
of  salicylate  of  soda  may  still  further  stimulate 
the  gland,  and  so  hasten  the  sweating  and 
general  abatement  of  the  symptoms.  Whether 
the  proceeding  is  beneficial  or  not  is  quite 
another  matter,  and  involves  the  whole  ques- 


136  THYROID    THERAPY 

tion  of  uses  and  abuses  of  antipyretics.  The 
patient  feels  better  with  a  fall  of  temperature 
and  a  good  sweat,  but  sometimes  the  tem- 
perature rises  again,  bringing  back  all  the 
previous  discomfort ;  and  in  this  case  we  may 
well  wonder  whether  we  have  been  premature 
in  our  efforts  or  not.  In  theory,  of  course, 
when  the  illness  is  commencing,  and  toxaemia 
still  slight,  if  by  a  few  doses  of  salicylates  or 
other  antipyretics  we  can  hurl  into  the  circula- 
tion enough  thyroid  secretion  to  form  anti- 
toxins or  annihilate  the  germs  by  whatever 
mode  is  usual,  we  may  then  congratulate  our- 
selves on  having  cut  short  the  attack.  How 
be  it,  our  method  may  have  been  extravagant, 
and  if  we  have  miscalculated  the  hidden  forces 
arrayed  against  us,  we  may  have  committed 
a  grave  strategical  error  which,  perhaps,  would 
not  have  been  done  by  Nature  unaided.  It  is, 
of  course,  possible,  or  even  probable,  that 
salicylates  have  an  action  which  is  hostile  to 
micro-organisms,  or  even  poisons  of  other 
origin,  and  that  benefit  accrues  from  such 
action  quite  apart  from  thyroid  influence.  But 
the  point  I  wish  to  lay  stress  on  is  that  salicy- 
lates have  a  powerful  influence  against  thyroid 
activity.  In  view  of  what  has  just  been  said, 
this  seems  a  startling  statement,  and  therefore 
requires  proof.  Whether  salicylates  powerfully 
stimulate,  and  so  rapidly  exhaust  thyroid 


THE    INFLUENCE    OF    SALICYLATES  137 

activity,  or  whether  they  actually  neutralize 
it,  which  in  the  case  of  an  active  gland  would 
stimulate  further  production  (like  lemon-juice 
and  saliva,  or  alkalies  and  gastric  secretion), 
I  cannot  say,  but  the  evidence  I  am  about  to 
bring  forward  points  to  the  latter  conclusion. 
I  will  quote  three  cases.  J.  D.,  a  robust 
adult,  had  an  acute  tonsilitis.  He  had  stuck 
to  his  work  for  three  or  four  days  when  I  first 
saw  him  one  morning.  He  had  then  taken 
to  his  bed  with  a  pulse  rate  of  1 20,  and  tem- 
perature 102°  F.  He  had  headache,  and 
aches  and  pains  in  the  limbs  severe  enough 
to  suggest  rheumatism,  but  possibly  only  in- 
fluenzal.  He  was  given  a  mixture  containing 
15-grain  doses  of  sodium  salicylate  and  half- 
drachm  doses  of  compound  tincture  of  cin- 
chona. But  owing  to  variations  in  the  size 
of  the  domestic  tablespoon,  he  took  repeatedly 
a  larger  dose,  roughly  20  grains  of  salicylate 
and  40  minims  of  bark  every  four  hours.  The 
error  was  not  discovered  for  thirty-six  hours. 
He  then  had  a  (morning)  pulse  rate  of  48, 
and  temperature  of  96*4°  F.  He  had  sweated 
profusely  the  first  night,  and  his  bowels  were 
obstinately  constipated,  resisting  strong  doses 
of  aperient.  The  pulse  and  temperature  re- 
mained at  this  low  level  all  the  next  day,  and 
the  bowels  were  still  obstinately  constipated  in 
spite  of  aperients,  though  the  salicylate  mix- 


138  THYROID     THERAPY 

ture  had  been  left  off.  Thyroid,  2^  grains 
twice  a  day,  was  then  given  for  two  days, 
and  the  temperature  again  rose,  this  time  to 
nearly  101°,  and  pulse  to  98.  The  throat  pro- 
gressed rather  slowly,  in  spite  of  energetic 
antiseptic  treatment,  which  had  given  me  ex- 
cellent results  in  other  cases.  The  patient 
returned  to  work  twelve  days  after  I  first  saw 
him,  when,  in  spite  of  full  doses  of  strychnine, 
he  had  a  very  soft  dicrotic  pulse  of  76  and 
a  blood  pressure  of  only  100  mm.  Hg.  I  have 
already  mentioned  that  this  patient  was  usually 
robust,  and  may  add  that  ordinarily  his  bowels 
were  remarkably  regular.  The  low  pulse  rate, 
the  dropped  temperature  and  obstinate  consti- 
pation, all  suggest  that  in  this  case  the  thyroid 
was  seriously  depressed  by  the  drugs  men- 
tioned. The  low  blood-pressure  was  probably 
due  to  the  same  cause,  inasmuch  as  high  blood- 
pressure  is  a  common  feature  of  Graves's 
disease.  If  this  interpretation  be  correct,  it 
is  probable  that  the  heavy  doses  administered 
did  harm  and  prolonged  convalescence. 

Case  No.  2  was  a  woman  of  39,  who  had 
suffered  from  life-long  constipation,  and  mani- 
fested the  ordinary  signs  of  thyroid  inadequacy. 
Her  general  condition  had  been  enormously 
improved,  and  constipation  much  lessened  by 
thyroid  medication.  On  one  occasion  her 
bowels  had  been  perfectly  regular  for  over  a 


THE    INFLUENCE    OF    SALICYLATES  139 

week  without  any  medicine  other  than  thyroid, 
and  she  could  not  remember  that  this  had  ever 
occurred  before.  At  the  time  of  which  I  now 
write  she  was  taking  a  small  dose  of  cascara 
nightly,  and  was  somewhat  tired,  owing  to 
disturbed  nights  entailed  by  her  duties  as 
nurse.  She  was  given  aceto-salicylic  acid  for 
a  slight  attack  of  lumbago,  and  though  the 
dose  did  not  at  any  time  exceed  10  gr.  thrice 
daily,  her  constipation  greatly  increased,  and 
the  nightly  dose  of  aperient  medicine  had  to 
be  more  than  doubled  while  taking  this  drug. 
It  is  only  reasonable  to  suppose  that  the 
increased  constipation  was  due  to  exaggeration 
of  the  thyroid  depression  caused  by  the  aceto- 
salicylic  acid. 

Case  No.  3  was  one  of  Graves's  disease.  I 
had  previously  found  aspirin  to  be  of  great 
value  in  controlling  paroxysms  of  tachycardia, 
and  accordingly  prescribed  a  daily  morning 
dose  of  10  gr.  for  this  patient,  who  usually  had 
an  attack  of  palpitation  after  breakfast.  The 
remedy  was  perfectly  successful,  and  in  view 
of  the  cases  just  quoted  I  resolved  to  try  the 
effect  of  three  or  four  doses  daily.  The  result 
was  rather  remarkable,  and  more  than  justified 
my  expectations.  The  pulse-rate  improved 
considerably,  and  the  patient  felt  very  much 
better.  Her  bowels,  which  had  previously 
been  open  twice,  and  often  three  times  a  day, 
were  now  open  but  once  daily.  She  increased 


14°  THYROID    THERAPY 

2  lb.  and  i  oz.  in  three  days.  Though  this 
increase  in  weight  might  be  attributed  to  faecal 
accumulation,  it  does  not  affect  the  argument, 
inasmuch  as  the  previous  intestinal  activity 
was  due  to  excessive  thyroid  action.  The 
only  objectionable  feature  was  some  gastric 
disturbance,  which  may  have  been  caused  by 
using  a  less  pure  substitute  for  aspirin. 
Sweating  was,  if  anything,  less  than  previously. 
More  prolonged  experience  of  this  treatment 
is  necessary  before  one  can  pronounce  final 
judgment,  but  I  think  it  proves  that  aspirin, 
and  possibly  other  salicylates  and  allied  drugs, 
will  be  found  of  inestimable  value  in  Graves's 
disease.  One  might  avoid  the  gastric  disturb- 
ance, and  possibly  get  still  better  results,  by 
local  use  of  one  of  the  easily  absorbed  salicylic 
compounds  directly  applied  to  the  skin  over 
the  thyroid  gland.  The  final  result  naturally 
depends  on  whether  thyroid  control  or  ex- 
haustion will  cure  Graves's  disease  or  other- 
wise, which  is  quite  another  question,  and  has 
already  been  discussed. 

Further,  in  view  of  the  beneficial  results 
recently  obtained  by  thyroidectomy  in  inoper- 
able cancer,  similar  benefit  might  be  obtained 
by  the  use  of  aspirin  in  such  cases,  many  of 
which  are  also  unsuitable  for  thyroidectomy. 
Aspirin  has  of  course  been  used  for  the  relief 
of  pain  in  cancer,  and  this  may  explain  the 
modus  operandi. 


CHAPTER  XII. 
General  Considerations. 

THERE  is  another  class  of  patients  who  are 
frequently  much  benefited  by  thyroid  treatment, 
though  in  their  case  a  cure  cannot  possibly  be 
expected,  which  is  in  itself  a  sufficient  reason 
for  doing  all  we  can  to  alleviate  them.  I  refer 
to  the  large  class  of  degenerates,  whose  cases 
of  course  vary  enormously  in  detail.  I  do  not 
wish  it  to  be  understood  that  I  look  on  thyroid 
deficiency  as  a  cause  of  their  degeneracy,  but 
an  examination  will  surprisingly  often  show 
that  it  is  a  very  important  concomitant  factor. 
This  result  may,  of  course,  be  brought  about 
in  two  different  ways :  Firstly,  the  cause  of 
degeneracy  may  also  cause  thyroid  depression 
directly  ;  and  secondly,  thyroid  depression  may 
very  readily  result  from  the  inaction  and  un- 
healthy life  which  infirmity  forces  on  the 
sufferers.  I  will  quote  two  cases  as  examples. 
The  first  is  a  congenital  idiot  whom  I  com- 
menced treating  six  months  ago.  Her  age 
was  then  6J  years,  and  from  the  history  I  have 
little  doubt  that  her  mother  suffered  from  a 


142  THYROID    THERAPY 

severe  attack  of  syphilis  several  years  before 
this  child  was  born.  The  first  child  was 
healthy,  then  followed  four  or  five  miscarriages, 
and  then  this  imbecile.  The  child,  when  first 
seen,  was  able  to  say  a  few  simple  words,  but 
rolled  the  eyes  and  head  about  in  a  horrible 
manner,  and  had  loud  snoring  respiration. 
She  exhibited  unceasing  movements,  not  only 
of  the  head  and  neck,  but  also  of  the  arms  and 
hands,  especially  the  left.  The  movements 
differed  from  those  of  chorea,  being  far  less 
jerky  and  spasmodic.  She  was  not  able  to  use 
the  left  hand  for  any  serviceable  purpose, 
owing  to  the  constant  movements,  and  though 
there  was  no  paralysis,  the  hand  was  constantly 
hyper-extended  and  grossly  distorted  in  many 
and  various  malpositions.  I  was  told  that  the 
child  suffered  from  paralysis,  but  the  malady 
appeared  to  me  to  depend  rather  on  want  of 
co-ordination.  The  individual  movements 
were  strong,  and  there  was  no  lack  of  power 
to  grasp,  or  to  flex  or  extend  the  wrist.  The 
same  lack  of  co-ordination  possibly  accounted 
for  inability  to  stand.  There  was  no  deformity 
of  the  limbs,  which  were  uniformly  ill-nourished, 
but  could  be  easily  moved  into  any  position 
desired.  Intelligence  appeared  to  be  sadly 
deficient,  and  the  child  could  not  be  left 
untended  for  a  moment,  except  in  bed.  As 
to  signs  of  thyroid  inadequacy  :  she  had  an 


GENERAL    CONSIDERATIONS  143 

operation  for  adenoids  when  ten  months  old. 
She  had  a  high  palatine  arch,  and  nearly  all 
the  temporary  teeth  were  badly  decayed,  many 
of  them  necessitating  extraction.  This  was 
done  under  gas  without  difficulty.  Her  mouth 
was  at  first  always  open,  and  usually  dribbling, 
but  she  could  breathe  without  distress  when  it 
was  held  shut.  She  had  a  poor  appetite,  was 
very  sensitive  to  cold,  and  suffered  from  chil- 
blains. She  had  no  excessive  thirst,  nor 
enuresis.  Her  hair  was  good,  and  had  never 
been  scanty.  The  bowels,  at  one  time  very 
constipated,  were  now  more  regular,  and  the 
new  teeth  (4  centrals  and  one  "  6  ")  were  good. 
Thus  there  obviously  had  been  many  signs 
of  thyroid  inadequacy,  though  the  general 
tendency  showed  improvement.  Nevertheless 
I  resolved  to  give  thyroid  treatment  a  trial, 
and  the  result  was  far  more  satisfactory  than 
one  could  have  anticipated.  The  first  thing 
noticeable  was  a  great  improvement  in  facial 
expression.  She  very  soon  obtained  co- 
ordination of  her  oculo-motor  muscles,  and  was 
able  to  hold  up  her  head  and  look  at  anything 
straight,  instead  of  rolling  her  eyeballs  up  into 
one  corner  or  under  the  lids,  with  the  head 
dropped  on  one  side.  She  also  gained  much 
more  control  over  her  hands.  As  the  mother 
expressed  it,  "she  did  not  knock  about  near 
so  much."  She  became  much  quieter  and  ate 


144  THYROID    THERAPY 

better.  In  a  month  she  was  able  to  sit  up  in 
a  chair,  which  she  had  never  done  before. 
She  commenced  to  talk  more,  imitating  her 
sister.  She  was  soon  able  to  sit  up  at  table  to 
have  her  meals,  and  according  to  the  mother's 
statement,  perceived  if  anything  usually  present 
were  lacking  from  the  table.  In  the  history 
of  a  case  like  this,  one  is  bound  to  accept  the 
statements  of  the  relatives  as  to  improvement, 
because  the  child  being  at  home,  improvement 
is  noticeable  in  a  number  of  little  things  which 
do  not  occur  under  the  eye  of  the  practitioner. 
Thus,  though  I  am  able  to  see  a  vast  improve- 
ment in  the  general  intelligence  of  the  child 
so  far  as  appearance  goes,  and  also  a  great 
lessening  of  the  involuntary  movements,  the 
parent's  affirmations  as  to  general  improve- 
ment are  much  more  enthusiastic.  And 
though  we  cannot  look  forward  to  the  child's 
becoming  a  genius,  the  mother's  statement 
that  "she  has  never  been  so  nice  as  she  is 
now "  is  worth  something,  and  in  view  of  the 
past  improvement  I  look  forward  with  con- 
fidence to  still  further  increase  of  intelligence 
with  age  and  experience. 

The  second  case  I  will  mention  is  that  of 
a  girl,  now  19,  who  had  "a  stroke"  at  the  age 
of  n,  affecting  her  speech  centre  and  para- 
lysing the  right  arm  and  leg.  Before  her 
calamity  she  was  said  to  be  a  bright  and 


GENERAL    CONSIDERATIONS  145 

intelligent  child,  well  advanced  in  her  school. 
For  some  months  she  was  silent  and  gave  no 
sign  of  comprehension  of  anything  that  was 
said.  Eventually  she  again  learned  to  talk,  and 
to  write  with  the  left  hand.  When  I  first  saw 
her  the  parents  said  she  was  not  so  well  as 
six  months  previously.  She  did  not  talk 
nearly  so  well,  had  given  up  her  writing,  and 
was  more  apathetic.  Her  speech  was  not 
exactly  a  drawl,  but  the  words  were  uttered 
slowly  and  deliberately  with  long  interspacing. 
Her  teeth  were  bad.  She  was  always  con- 
stipated and  perhaps  a  little  unduly  sensitive 
to  cold,  both  of  which  symptoms  would  be 
natural  to  a  paralytic.  Now  though  the 
symptoms  did  not  point  strongly  to  thyroid 
inadequacy,  there  was  no  doubt  at  all  that 
the  administration  of  thyroid  did  her  a  lot 
of  good.  She  was  given  2\  gr.  daily 
in  divided  doses,  and  not  only  her  parents 
noticed  a  great  improvement,  but  also  her 
friends.  The  girl  was  much  brighter  and 
talked  a  great  deal  better.  She  told  me  her- 
self she  had  been  very  bright  all  the  week, 
and  there  was  no  reason  to  attribute  the 
improvement  to  any  other  factor,  because  her 
routine  life  was  unaltered,  and  I  had  only  seen 
her  once  and  did  not  hold  out  any  delusive 
hopes  of  cure ;  so  one  could  hardly  attribute 
the  improvement  to  suggestion,  and  it  was 

10 


146  THYROID    THERAPY 

highly  improbable  that  such  improvement  could 
result  from  the  cheering  influence  of  a  solitary 
visit  from  a  stranger. 

Enough  has  now  been  said  about  thyroid 
secretion  to  show  that  there  are  a  vast  number 
of  conditions  in  which  good  may  rationally 
be  expected  from  judicious  thyroid  therapy. 
Perhaps  the  most  satisfactory  cases  will  be 
those  of  minor  thyroid  inadequacy,  especially 
in  children.  These  cases  are  not  difficult  to 
diagnose  with  a  little  practice,  and  are  exceed- 
ingly common.  One  of  the  most  striking 
things  about  them  is  that  often  there  is  no 
tangible  complaint  to  which  a  name  has  been 
given,  and  other  lines  of  treatment  have 
usually  been  tried  and  proved  unsatisfactory. 
The  symptoms  as  described  by  Leonard 
Williams  have  already  been  discussed  and 
illustrated  by  an  extreme  case  in  Chapter  I. 
In  older  people  too,  especially  women,  it  is 
probably  no  exaggeration  to  say  that  thyroid 
inadequacy  is  just  as  common  as  anaemia,  and 
equally  important  in  its  results.  There  is, 
however,  this  important  difference,  that  nearly 
everyone  can  diagnose  anaemia,  whereas  it 
takes  considerable  technical  knowledge  to 
diagnose  thyroid  inadequacy.  So  far  as  treat- 
ment goes,  thyroid  inadequacy  is  on  the  whole 
the  more  satisfactory  condition,  but  often  goes 
hand-in-hand  with  anaemia.  As  to  dosage, 


GENERAL    CONSIDERATIONS  147 

Leonard  Williams'  principle  of  giving  the 
smallest  dose  found  to  be  satisfactory,  is  cer- 
tainly the  best.  For  children,  doses  of  j-  to 
i  gr.  t.d.s.  will  commonly  be  found  effective, 
With  adults,  I  have  found  a  dose  of  i  gr. 
three  times  a  day  usually  satisfactory,  but 
headache  occasionally  results  even  from  this 
quantity,  especially  if  combined  with  small 
doses  of  iodide. 

The  special  actions  of  calcium,  arsenic  and 
iodides  have  already  been  discussed,  and  these 
drugs  may  be  prescribed  or  withheld  accord- 
ing to  the  judgment  of  the  prescriber.  I  can- 
not say  I  am  in  favour  of  adding  them  as  a 
matter  of  routine,  though  apparently  such  is 
the  practice  advocated  by  Leonard  Williams, 
whose  experience  is  of  longer  duration  than 
mine.  The  duty  of  the  thyroid  in  dealing  with 
poisons  such  as  may  be  formed  within  the  body 
by  disease  is  an  argument  in  favour  of  ad- 
ministering thyroid  at  the  onset  of  acute 
illnesses.  But  there  is  possibly  a  doubt 
whether  thyroid  administered  by  the  mouth 
has  the  same  power  of  neutralizing  toxins  as 
the  naturally  generated  secretion.  There  is 
also  the  question  whether  administration  of 
thyroid  by  the  mouth  may  not  exercise  an 
inhibitory  effect  on  the  patient's  own  secretion. 
If  such  be  the  case,  and  thyroid  tabloid  be  less 
efficient  than  the  patient's  own  secretion,  we 
may  obviously  be  doing  harm. 


148  THYROID    THERAPY 

This  might  be  a  reason  why  tuberculous 
patients  are  sometimes  made  worse  by  thyroid. 
On  the  other  hand,  such  an  inhibitory  influence 
might  well  be  productive  of  good  in  cases  of 
thyroid  exhaustion  by  giving  physiological  rest 
to  an  overworked  gland.  The  addition  of 
arsenic,  iodides  or  calcium  would  all  theoreti- 
cally tend  to  prevent  inhibition  of  the  gland's 
own  activity,  and  that  this  is  so  I  have  proved 
for  myself  and  accept  as  a  definite  fact.  The 
theory  of  inhibition  might  even  explain  the 
failure  to  cure  nocturnal  enuresis  when  too 
large  a  dose  of  thyroid  is  administered,  which 
Leonard  Williams  cautions  us  against.  In 
this  case,  naturally,  the  larger  the  dose  of 
thyroid,  the  more  the  patient's  own  gland 
would  be  inhibited.  There  may  be  some 
virtue  in  the  patient's  own  thyroid  secretion, 
not  present  in  an  active  form  in  the  dried 
preparation,  which  virtue  saves  the  normal 
individual  from  the  troubles  of  enuresis.  A 
minute  dose  of  thyroid  substance  administered 
by  the  mouth  may  possibly,  by  doing  some 
other  part  of  the  thyroid's  work,  eke  out  the 
patient's  own  secretion  for  this  purpose  without 
exercising  any  inhibitory  effect.  But  it  is  diffi- 
cult to  suppose  that  nocturnal  enuresis  may 
result  equally  from  deficiency  or  surplus  of 
thyroid  secretion,  and  there  are  other  difficul- 
ties also. 


GENERAL   CONSIDERATIONS  149 

If  enuresis  be  due  to  thyroid  deficiency, 
why  does  it  usually  occur  in  the  night  rather 
than  the  day  ?  Surely  more  demands  are 
made  on  the  activity  of  the  gland  during  wak- 
ing hours  than  in  those  of  sleep  ?  Are  we  to 
argue  that  the  gland  is  therefore  exhausted  by 
nightfall,  and  only  by  virtue  of  the  night's 
repose  becomes  capable  of  saving  the  patient 
from  diurnal  enuresis  also  ?  Or  that  because 
rest  lessens  thyroid  activity,  therefore  in  the 
absence  of  stimulation  engendered  by  exercise, 
secretion  immediately  becomes  deficient,  and 
enuresis  results? 

Such  arguments,  even  if  accepted,  would 
only  explain  the  helpful  effect  of  small  doses, 
not  the  contrary  effect  of  larger  doses. 

Can  it  be  that  the  condition  is,  after  all,  not 
directly  due  to  deficiency,  but  to  a  temporary 
excess  of  thyroid  secretion  ?  A  condition  of 
thyroidorrhcea,  if  one  may  coin  such  a  word. 
Such  thyroidorrhcea  (like  spermatorrhoea) 
resulting  from  and  maintaining  a  relatively 
exhausted  condition  of  the  gland,  and  therein 
differing  from  Graves's  disease.  Such  a  condi- 
tion might  readily  improve  under  thyroid  medi- 
cation, but  it  is  easy  to  see  that  if  enuresis 
were  due  to  a  momentary  excess  of  thyroid 
secretion  in  the  system,  an  overdose  of  the 
drug  would  produce  a  similar  result.  This 
hypothesis  would  explain  the  beneficial  influ- 


I5O  THYROID    THERAPY 

ence  of  belladonna,  which  has  probably  secured 
more  successes  in  enuresis  than  most  other 
drugs  have  done.  I  recently  had  a  case  of 
enuresis  which  proved  refractory  to  thyroid  in 
small  or  large  doses.  It  was,  however,  defin- 
itely worse  on  large  doses.  Accordingly  I 
decided  to  try  aspirin,  with  the  idea  that  it 
might  neutralize  some  of  the  excessive  secre- 
tion. The  immediate  result  was  a  dry  bed  for 
three  nights,  an  occurrence  previously  unknown 
in  this  case,  though  the  child  was  1 1  years  old. 
The  next  three  or  four  nights  the  bed  was 
wetted  only  once,  and  then  aspirin  failed  us 
altogether.  The  dose  given  was  5  grains  three 
times  a  day,  and  I  suppose  the  explanation  is 
that  the  child's  thyroid,  finding  more  work  to 
do,  was  stimulated  to  still  greater  efforts  and 
an  excess  of  secretion  was  again  produced, 
with  a  return  of  enuresis  as  the  result.  One 
might,  of  course,  suggest  an  alternative  explan- 
ation that  enuresis  was  due  to  deficiency,  and 
the  brief  respite  due  to  the  stimulating  effect 
of  aspirin  on  the  thyroid,  which,  however,  soon 
became  still  more  exhausted  and  was  unable  to 
respond  further.  In  that  case,  however,  a 
return  to  thyroid  medication  should  have  been 
successful.  But  it  proved  futile.  Another 
point  is  that  this  child  did  not  exhibit  sym- 
ptoms of  thyroid  deficiency  in  any  very  marked 
degree.  She  was  well  grown,  not  unduly  sen- 


GENERAL    CONSIDERATIONS  151 

sitive  to  cold  and  had  a  big  appetite.  Her 
teeth  were  very  fair,  tonsils  not  enlarged  and 
she  had  free  nasal  respiration,  though  some 
small  adenoids  might  have  been  present.  She 
had  a  high  palatine  arch  and  always  looked 
puffy  under  the  eyes,  but  on  the  whole  general 
health  was  good  and  I  could  find  no  other 
defect.  She  was  not  suffering  from  worms, 
and  her  bowels  were  not  constipated. 

It  has  not  been  my  experience  that  the  most 
marked  cases  of  thyroid  deficiency  commonly 
surfer  from  enuresis,  though  the  victims  of 
enuresis  very  commonly  do  exhibit  one  or 
more  other  signs  of  thyroid  inadequacy,  and 
have  usually  proved  amenable  to  small  doses 
of  thyroid  as  suggested  by  Leonard  Williams. 
The  small  doses  may  act  by  inhibition,  check- 
ing excessive  thyroid  activity,  but  perhaps  it  is 
more  likely  that  they  alleviate  and  so  restore 
to  a  healthy  balance  the  secretions  of  the 
patient's  own  gland. 

In  such  cases,  of  course,  there  might  be 
some  advantage  to  be  gained  by  stirring  into 
activity  the  patient's  own  gland  with  such 
drugs  as  arsenic,  iodine  and  calcium,  provided 
the  gland  were  able  to  respond,  and  I  find 
iodide  of  iron  among  the  remedies  for  enuresis 
mentioned  by  Sir  Lauder  Brunton.  There  is 
another  matter  which  needs  caution,  and  that 
is  the  preparation  of  thyroid  which  is  used. 


152  THYROID    THERAPY 

There  are  probably  some  on  the  market  which 
are  inactive.  It  is  only  natural  that  the  pro- 
perties and  activity  of  the  gland  should  vary 
in  different  animals,  according  to  their  age  and 
sex,  and  probably  even  according  to  their 
pasturage. 

Reference  has  already  been  made  to  goitrous 
sheep  and  cretin  lambs  living  in  districts  where 
the  vegetation  is  deficient  in  iodine.  Accord- 
ingly, some  thyroids  are  certainly  unsuitable 
for  medical  use,  and  I  am  informed  that 
experts  in  this  particular  branch  are  able  to 
select  the  good  and  reject  the  bad,  which 
selection  might  well  prove  difficult  to  the 
uninitiated.  The  proper  percentage  of  iodine 
is  at  least  '2,  which  should  be  present  in 
natural  condition.  I  would  have  nothing  to 
do  with  preparations  containing  added  iodine. 
As  to  the  mode  of  dispensing  :  the  drug  may 
be  given  of  course  in  tabloid  form,  or  what  is 
more  convenient,  the  requisite  amount  may 
be  ground  up  in  a  mortar  with  water  and 
incorporated  in  the  mixture,  which  may  con- 
tain any  other  drugs  indicated.  If  desiccated 
thyroid  be  used  for  this  purpose,  due  attention 
must  be  given  to  the  fact  that  it  is  five  times 
as  strong  as  the  ordinary  tablet  form.  This  is 
not  expensive  for  those  who  dispense  their  own 
medicine,  the  cost  of  the  small  doses  becoming 
almost  infinitesimal.  <{  Shake  the  bottle  "  is 


GENERAL   CONSIDERATIONS  153 

a  necessary  adjunct,  and  the  mixture  must 
not  contain  pepsin.  I  was  astonished  at  the 
amount  of  colloid  produced  by  the  addition 
of  pepsin  to  a  bottle  containing  i\  gr.  of  de- 
siccated thyroid.  The  substance  thus  formed 
adequately  demonstrates  the  true  meaning  of 
the  word.  The  incorporation  of  the  substance 
in  the  medicine  has  many  obvious  advantages, 
doing  away  with  any  explanation  as  to  what 
"  the  little  tablets  "  are  for,  or  as  to  why  they 
should  also  be  given  to  other  members  of  the 
household  whose  cases  may  be  widely  different 
in  other  respects.  It  is  perhaps  well  to  add 
that  success  in  this  form  of  treatment  is  far 
more  likely  to  be  gained  by  those  who  keep 
careful,  if  brief,  notes  of  their  cases,  special 
attention  being  paid  to  such  symptoms  as 
pulse-rate,  headache,  sensation  of  being  hot  or 
cold,  regularity  of  bowels,  and  weight.  If  the 
indications  and  dose  have  been  correctly 
gauged  the  patient  will  speedily  come  with 
assertions  of  amelioration.  The  mother  will 
find  the  child  easier  to  feed  and  in  every  way 
more  amenable,  and  the  adult  will  feel  much 
brighter  and  less  fatigued.  Naturally  there 
are  many  cases  in  whom  this  line  of  treatment 
is  contra-indicated,  but  the  pathological  cases 
are  not  nearly  so  common  as  the  thyroid 
deficients.  Many  of  course  are  in  the  pink  of 
health  and  do  not  come  into  this  category,  but 
ii 


154  THYROID    THERAPY 

some  cases  of  thyroid  excess  which  do  not 
amount  to  Graves's  disease  will  be  found  among 
those  individuals  who  are  almost  fresh-air 
maniacs,  and  only  feel  really  well  in  winter. 
Such  people  constantly  find  the  fire  too  big, 
perspire  easily,  and  are  apt  to  feel  very  limp  in 
summer.  They  dislike  fat,  and  often  prefer 
jam  and  other  sweets  to  butter.  They  never 
need  aperients,  and  are  dften  energetic,  and 
sometimes  excitable  and  impulsive.  And  if 
they  happen  to  reside  in  the  same  house  as 
the  victims  of  thyroid  deficiency,  the  contrast 
is  most  interesting  to  observe.  But  this  is 
a  subject  whose  realms  may  well  be  further 
explored,  and  I  fancy  that  not  a  few  examples 
will  be  found  among  neurasthenics,  and  pos- 
sibly also  in  lunatic  asylums. 


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BIOLOGY 

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